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RD131  G792  1918  The  nature  and  treat 


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The  Nature  and  Treatment  of 

Wound  Shock  and  Allied 

Conditions 


W.     B.     CANNON,     M.D.     (Boston) 

Captain,  M.  R.  C,  U.  S.  Army 

E.     M.     C  O  W  E  L  L 

Captain,  R.  A.  M.  C,  S.  R. 

JOHN    ERASER,    M.D.,    F.R.C.S.,    (Edin.) 

Captain,  M.  C,  R.  A.  M.  C. 

A.     N.     HOOPER 

Captain,  R.  A.  M.  C. 
FRANCE 


Report  No.  2,  Special   Investigation  Committee,  Medical 
Research  Committee,  (Great  Britain) 


Rcl>riiited  from    The  Journal  of  the  American  Medical  Association 

Feb.  23,  191S,   Vol.  70.  pp.  520-535,  and  March  2, 

1918,  Vol.  70.  pp.  607-621 


Copyright,    1918 

American    Medical   Association 

Five  Hundred  and  Thirty-Five  North  Dearborn  Street 

CHICAGO 


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The  Nature  and  Treatment  of 

Wound  Shock  and  Allied 

Conditions 


W.     B.     CANNON,     M.D.     (Boston) 

Captain,  M.   R.   C,  U.   S.  Army 

E.     M.     C  O  W  E  L  L 

Captain,  R.  A.  M.  C,  S.   R. 

JOHN    ERASER,    M.D.,    F.R.C.S.,    (Edin.) 

Captain,  M.  C,  R.  A.  M.  C. 

A.     N.     HOOPER 

Captain,  R.  A.  M.  C. 
FRANCE 


Report  No.  2,  Special   Investigation  Committee,  Medical 
Research  Committee,  (Great  Britain) 


Copyright,    1918 

American    Medical   Association 

Five  Hundred  and  Thirty-Five  North  Dearborn  Street 

CHICAGO 


2- 


PREFACE 


In  August,  1917,  the  Medical  Research  Committee  (Great 
Britain)  appointed  a  Special  Investigation  Committee  to 
undertake  the  coordination  of  inquiries  into  surgical  shock 
and  allied  conditions,  with  a  view  to  the  better  correlation  of 
laboratory  and  clinical  observations.  The  following  were 
asked  to  serve  on  this  committee: 

Prof.   E.   H.    StarlinK,   M.D.,   F.R.S.    (Chairman). 

Prof.   F.   A.   Bainbridge,  M.D.,   F.R.C.P. 

Prof.   W.   M.   Bayliss,  D.Sc,   F.R.S. 

Prof.   W.    B.    Cannon,   M.D.    (Harvard   University). 

Lieut.-Col.   T.   R.   Elliott,   M.D.,   F.R.S.,   E.A.M.C. 

John  Fraser,  M.D.,  F.R.C.S.   (Edin.). 

Prof.    A.    N.    Richards,    Ph.D.     (University    of    Pennsylvania). 

Prof.  C.   S.  Sherrington,  M.D.,  Sc.D.,  F.R.S. 

Col.    Cuthbert   Wallace,   C.M.G.,   F.R.C.S. 

H.  H.  Dale,  M.D.,  F.R.S.   (Secretary). 

The  first  report  on  "Intravenous  Injections  to  Replace 
Blood"  was  published  as  a  special  Bulletin,  Nov.  25,  1917.  The 
second,  on  "Investigation  of  the  Nature  and  Treatment  of 
Wound  Shock  and  Allied  Conditions,"  which  follows,  was 
issued  for  official  use,  Dec.  25,  1917,  and  Sir  Walter  Fletcher, 
secretary  of  the  Medical  Research  Committee,  has  given  his 
consent  to  the  publication  of  the  papers  in  The  Journal,  as 
has  also  the  military  censor. 

In  sending  the  report,  Dr.  Cannon  writes: 

"The  work  was  done  in  a  casualty  clearing  station  a  few  miles  from 
a  part  of  the  line  where  there  has  been  constant  fighting  for  three  years 
with  scarcely  any  change.  Only  the  most  serious  cases  which  could 
not  be  reasonably  moved  any  farther  back  were  left  with  us  for  the 
town  was  repeatedly  shelled  and  the  station  was  twice  bombed  by  aero- 
planes during  my  stay.  London,  with  its  air  raids,  is  a  Paradise  by 
comparison." 


CONTENTS 


CLINICAL     STUDY     OF     ]UX)OD     PRES- 
SURE    IN     WOUND     CONDITIONS     ..  9 

Introduction 9 

(a)  Instruments  Employed  and  Methods 

of  Invcsligation 9 

(&)   Control   Blood   Pressure   Readings  10 

The  Blood  Pressure  as  Observed  in  Vari- 
ous Wound  Conditions 11 

(a)  Head  Wounds 12 

1.  Scalp  Wounds      12 

2.  Compound  Fracture  of  Skull 

with  Dura  Intact     .  .      .  .  12 

3.  Penetrating  Wounds  of  Skull  12 

4.  Perforating- Wounds  of  Skull  12 

5.  The  Effect  of  Anesthesia  on 

the  Blood  Pressure  Read- 
ings of  Head  Wounds    .  .  14 

6.  Summary       15 

(&)  Abdominal    Wounds        15 

(c)  Chest    Wounds         20 

(d)  Mtdtiple   Wounds  and   Wounds  of 

Extremities 21 

Blood  Pressure  Readings  as  Studied  Sub- 
sequent TO  Various  Intravenous  In- 
fusions            22 

{a)  Physiologic   Sodium    Chlorid        ..  22 

(b)  Ringer's  Solution  and  Its  Modifica- 

tions          24 

(c)  Colloidal  Solution 24 

{d)  Direct  Blood  Transfusion     .  .      . .  29 

(e)  Glucose  Solution      30 

(/)   Other  Measures       .  .      .  ^     .  .      .  .  30 

'  {g)   Conclusions        30 


6 

PrESSIRE       OnSERVATIONS       IN       THE       FlRST 

Week  of  Convalescence  as  an  Aid  to 
Prognosis  and  Treatment      M 

SOME  ALTERATIONS  IN  DISTRIBU- 
TION AND  CHARACTER  OF  BLOOD  IN 
SHOCK     AND     HEMORRHAGE       ..     ..     32 

Introduction 32 

The  Blood  Changes  Peculiar  to  Shock     33 

The  Blood  Changes  Peculiar  to  Hemor- 
•  rhage     39 

Postoperative  Blood  Changes  • 40 

Blood  Changes   Obskrvi:d   afti;r   ^^\RIOus 

Injections 42 

(a)  Blood  Transfusion 42 

{b)  Injection  of  Gum  Solution     .  .      .  .  42 

(c)  Hypertonic  Saline  Injections       . .  43 

The  Value  of  Blood  Examinations  for 
Prognosis      44 

(a)  The  Significance  of  Continued  Con- 

centration   of    Pcnphcral    Blood    44 

(b)  The    Significance     of    Progressive 

Dilution    of    the    Blood     . .      .  .     45 

Summary        .  .        46 

ACIDOSIS  IN  CASES  OF  SHOCK,  HEM- 
ORRHAGE   AND    GAS    INFECTION     ..     47 

Introduction 47 

The  Relation  of  Acidosis  to  Blood  Pres- 
sure,   Pulse    and    Respiration      . .      .  .  49 

(a)  Relation  to  Blood  Pressure    .  .      .  .  49 

(b)  Relation  to  Pulse     51 

(c)  Relation  to  Respiration 52 

The    Sugar    Content    of   the    Blood     . .     53 

The  Effect  of  Anesthesia  and  Operation 
ON  Existent  Acidosis  and  Low  Blood 
Pressure       '   . .     54 


7 

Alkalini':    TRi;Arivii';NT    of    ICxtricmt:    Aci-  ' 

Dosis  IN  Shock 58 

Summary        60 

THE    INITIATION    OF    WOUND    SHOCK  61 

Introduction         61 

Physiology  of  the  FjofiTiNG  Soldier       .  .  62 

Classification   of  Wounds   with    Refer- 
ence to  the  Incidence  of  Wound  Shock  63 

Class  A.     Trivial  Wounds 63 

Class  B.     Mhderatcly    Severe    Wounds  CA 

Class  C.     Scriotcs    Wounds 67 

Conclusions 70 

A    CONSIDERATION    OF    THE    NATURE 

OF  WOUND  SHOCK 71 

Introduction 71 

The  Bearing  of  Present  Work  on  Pre- 
vious Theories  of  Shock       71 

(a)  The  Acapnia  Theory       71 

(b)  The  Idea  of  Suprarenal  Exhaustion  74 

(c)  The  Nerve  Exhaustion  Theory     .  .  75 

The  Cardiac  Factor 78 

The   ProSlem    of   the    "Lost    Blood"    in 

Shock      79 

In    the    Arteries? 79 

In  the  Veins r .  .  80 

1)1  the  Capillaries!' 81 

The  Viscosity,  Factor 83 

The  Effects  of  Acidosis  on  the  Circu- 
lation      85 

Vicious  Circles  in  Shock 88 

Shock  as   "Exemia" 89 

A  Concept  of  the  Development  of  Shock 

OR  EXEMIA     . ,      , .      , .      . ,      , 90 


8 

THE      PREVENTIXl'      TREATMENT      OE 
WOUND    SHOCK 93 

Introduction 93 

The   Prevention    and   Eaklv    Tki:atmi:nt 
OF   Wound    Shock     . .     94 

Modifications   of   Tkkatmknt   in    I'aitij-: 
Conditions 98 

Protection  Against  tih-:  Effi^cts  of  Slr- 
GiCAL    Operation        98 

Preoperative  Prophylaxis 99 

Operative  Prophylaxis       100 


CLINICAL    STUDY    OF    BLOOD    PRESSURE 
IN     WOUND    CONDITIONS  * 

JOHN     FRASER 

Captain,  M.  C,  R.  A.  M.  C. 
AND 

E.    M.    COWELL 

Captain,  R.  A.  M.  C,  S.  R. 

FRANCE 

Introduction 

For  a  period  of  over  two  years  we  have  been  reading 
and  recording  the  blood  pressures  in  a  variety  of 
wound  conditions.  Certain  of  the  observations  have 
been  sufficiently  interesting  to  warrant  their  record- 
ance. 

The  results  may  be  summarized  under  various 
headings : 

(a)  Control  blood  pressure  readings. 

(b)  The  blood  pressure  as  observed  in  wound  con- 
ditions. 

(c)  Blood  pressure  readings  as  studied  subsequent 
to  various  intravenous- infusions. 

(d)  Observations  on  the  blood  pressure  in  the  first 
week  of  convalescence. 

The  readings  published  in  this  paper  have  been  made 
at  a  casualty  clearing  station,  except  where  otherwise 
stated. 

A.     INSTRUMENTS     EMPLOYED     AND     METHODS     OF 
INVESTIGATION 

We  have  employed  several  forms  of  mercury 
manometers,  and  of  these  generally  the  "Riva-Rocci" 
instrument.  Lately  we  have  been  using  a  spring 
sphygmomanometer.  It  would  appear  that  the  mer- 
cui*y  instruments  give  the  most  accurate  readings  of 
the  systolic  pressure,  but  it  is  difficult  to  obtain  with 
them  a  correspondingly  exact  reading  of  the  diastolic 

*  Discrepancies  between  the  methods  reported  in  this  paper  and  those 
reported  in  later  papers  are  accounted  for  by  the  fact  that  this  paper 
had  been  completed  and  presented  to  the  Medical  Research  Committee 
before  the  work  which  appears  in  the  subsequent  papers  was  begun. 


10 

prt'ssnrc.  The  spring  instnnneiit,  which  from  a 
iiio^'haiiical  point  of  view  cannot  be  as  accurate  as  a 
mercury  coUuiin,  certainly  f^ives  a  more  easily  api)re- 
ciatcd  rcachng  of  the  diastolic  or  minimum  jircssurc. 
A  great  advantage  of  the  former  is  its  adaptability  and 
small  compass,  allowing  it  to  be  easily  carried  in  the 
pocket.  \\'ith  this  instrument,  many  pressure  observa- 
tions on  recently  wounded  men  were  made  in  the 
trenches,  and  in  the  advanced  dressing  stations  of  field 
ambulances.  In  certain  cases  in  which  the  peri])heral 
pulse  can  hardly  be  appreciated,  it  is  necessary  to  read 
the  pressure  by  means  of  the  stethoscope.  Such  read- 
ings are  very  accurate,  and  a  result  can  be  obtained 
when  no  pulse  can  be  felt.^  Readings  have  been  made 
of  the  systolic  or  maximum  ])rcssure,  of  the  diastolic  or 
minimum  pressure,  and  of  the  pulse  pressure. 

B.     CONTROL     BLOOD     PRESSURE     READINGS 

A  very  large  number  of  control  readings  were  made 
from  healthy  soldiers.  As  was  to  be  expected,  a  wide 
range  of  results  was  obtained.  The  readings  of  the 
systolic  pressure  were  slightly  lower  than  the  records 
one  would  have  accepted  as  normal  in  civil  practice. 
Over  a  wide  series  of  cases  the  average  systolic  or 
maximum  pressure  worked  out  at  fronrl  10  to  120,  and 
the  diastolic  or  minimum  pressiire  at  from  70  to  80, 
while  the  pulse  pressure  averaged  40  mm.  Wt  made 
what  may  be  considered  an  interesting  observation, 
that  among  soldiers  engaged  in  the  actual  fighting, 
more  especially  infantrymen,  the  average  systolic 
pressure  worked  out  at  a  higher  figure  than  among  men 
of  the  same  regiment  in  support,  where  they  were  only 
exposed  to  occasional  fire. 

It  was  noticed  that  the  raised  pressure  of  the  fighting 
man  tended  to  drop  quickly  when  he  was  resting  away 
from  the  firing  line;  for  instance,  a  systolic  pressure 
of  140  mm.  dropped  to  110  mm.,  or  even  to  100  mm. 

Observations  were  made  on  a  series  of  pilots  and 
observers  before  and  after  a  two  hours'  aeroplane 
bombing  raid;  the  a-verage  systolic  pressure  was  135 
mm.,  and  it  remained  constant  on  return.  In  only  one 
case  the  pressure  was  raised  by  10  mm. 

1.  Latterly  wc  have  used  this  method  to  the  exclusion  of  all  others. 


11 

The    Blood    Pressure    as   Ojjserved    in 
Various    Wound    Conditions 

Pressure  readings  taken  in  the  line  on  various  tyjjes 
of  wounds,^  at  very  short  intervals  after  the  jjaticnl 
had  been  wounded,  show  two  distinct  groups: 

1.  The  hypertension  group,  in  which  the  systolic 
pressure  varies  from  150  to  160  or  even  170  mm. 

2.  The  hypotension  group  (with  primary  shock),  in 
which  the  pressure  varies  from  40  to  90  mm. 

In  the  number  of  cases  examined  at  this  early  period, 
there  were  practically  none  that  occupied  an  intermedi- 
ate position,  that  is,  showing  a  normal  blood  pressure. 

The  pressure  of  patients  in  Group  1,  after  resting 
and  the  journey  to  the  casualty  clearing  station,  gradu- 
ally falls,  and  in  the  case  of  a  normal  recovery  with 
rest  in  bed  the  systolic  pressure  remains  at  a  steady 
level  between  110  and  120  mm. 

In  Group  2,  the  patients  are  cold,  often  pulseless,  and 
many  of  them  suffer  from  severe  thoracic  or  abdom- 
inal wounds.  Occasionally  the  anatomic  lesion  appears 
to  be  entirely  out  of  proportion  to  the  physiologic  reac- 
tion ;  for  example,  a  simple  bullet  wound  of  the  buttock 
was  accompanied  by  a  systolic  blood  pressure  of  50 
mm.  at  the  end  of  the  three  hours. 

In  this  group  intense  primary  shock  is  present,  and 
with  the  occurrence  of  hemorrhage,  secondary  shock 
develops  and  the  pressure  continues  to  fall. 

Following  the  application  of  treatment,  arrest  of 
hemorrhage  and  pain,  with  rest  and  warmth,  the  blood 
pressure  may  become  partially  reestablished. 

A.     HEAD     WOUNDS 

1.  Scalp  Wounds. — These  showed  a  slight  elevation 
in  blood  pressure  readings ;  all  the  cases  which  we  had 
an  opportunity  of  examining  varied  between  120  and 
130  in  systolic  pressure,  with  a  mean  diastolic  pressure 
of  100. 

2.  As  the  result  of  further  observations  made  in  the  front  line 
trenches,  the  pressures  of  early  wounded  are  divided  into  three  groups 
(Cowell,  E.  M.:  The  Initiation  of  Wound  Shock,  p.  61):  (a)  Trivial 
wounds,  in  which  there  is  no  alteration  in  pressure  or  tension.  (6) 
Moderately  severe  and  not  immediately  endangering  life,  in  which  there 
is  no  primary  shock,  but  in  certain  circumstances  secondary  shock 
develops,  (c)  Severe  wounds,  in  which  unavoidable  primary  shock  is 
present. 


12 


2.  Compotmd  Fracture  of  Skull  icith  Dura  Intact. — 
These  cases  showed  a  high  systolic  pressure ;  with  one 
exception  all  the  cases  that  we  had  an  opportunity  of 
examining  registered  a  systolic  pressure  of  140  mm. 
and  over. 

The  single  exception  showed  a  systolic  pressure  of 
100  mm.,  but  such  a  low  reading  could  be  explained  by 
the  fact  that  associated  with  a  ver>'  extensive  fracture 
of  the  bone  there  was  profuse  hemorrhage  from  the 
meningeal  and  scalp  vessels. 

3.  Penetrating  Wounds  of  Skull.  That  Is,  Compound 
Fracture,  Dura  Tom  coid  Foreign  Body  Retained. — On 


■ 

«c 

c 

J 

r 

1 

c 

p    ( 

p 

c 

>    c 

) 

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-- 

— 

... 

1 

1    1 

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Chan   1. — Blood   pieasuie   in   scalp  wounds 

examination  of  these  cases  it  was  found  that  as  a  rule 
a  low  blood  pressure  was  registered.  The  systolic 
pressure  varied  from  60  mm.  to  112  mm.  over  a  series 
of  cases.  It  was  interesting  to  observe  that  the  dias- 
tolic pressure  closely  corresponded  to  the  systolic 
pressure  with  a  correspondingly  low  pulse  pressure. 
We  can  offer  no  explanation  of  this  feature,  which  was 
relatively  constant  throughout  this  type  of  case.  The 
wounds  were  such  as  not  to  result  in  increased  intra- 
cranial pressure. 

4.  Perforating  IVounds  of  Skull. — In  types  of  per- 
forating wounds — that  is  to  say,  with  entrance  and 
exit  wounds — the  blood  pressure  readings  could  be 


dh'ided  into  two  groujis,  oue  in  which  the  systolic  read- 
ing was  hig'h,  varying  from  3K)  to  170  mm.,  and  a 
«>eooDd  group  in  M'hich  the  readings  were  low,  var)'ing 
frana  100  to  110  mm.  This  subdi\ision  corresponds  to 
a  oontain  anatomic  distribution.     The  first  group  of 


Blood 

Pressure 

c 

fr^LT^rL                1 

1 —                   .    " 
O'f  Siu/f  uiil^  dura  infpct 

case    numLer  :  — 

'SO 

no 

WD 

c 

c 

)           C 

5 

• 

M 

\       t 

k            ' 

i 

) 

-5^  Spec/a/  Case 
uirfh  profuse 
JicerrtorrhcDC 

r.* 

i 

-  .  irs.^e    rV^rrr^c:  '  5^^li<: 

Sijsfol'C      rrt:~^rz         Q 
DiasTolic  Pressure      ^ 

Chart   2. — Blood   press-are   i::    coicpound   fracture    with    dnra   intact. 


pressure  readings  consisted  of  those  in  which  the 
liajongia-and-through  wounds  involre  the  xentricles, 
aaad  •were  accconpanied  by  hemorrhage  into  the  ca^-ities 
of  tibe  ventricle? . 


14 


In  the  second  i^idnp  the  wounds  had  involved  the 
hrain  more  or  less  su] )erl"Kially,  and  jrcnerally  occurred 
in  varyiu}^  axes  of  the  frontal  and  tK'cipital  regiojis. 

Daily  readings  in  i)atients  recoverinij  after  operation 
for  the  second  type  of  wound  show  that  the  systolic 
j)ressure  is  maintained  at  a  constant  level  of  from  110 
to  120  mm.  as  long  as  convalescence  is  uncomplicated. 
The  onset  of  meningitis  is  accomj^anied  by  a  rise  of 
blood  pressure  corresponding  to  the  increase  in  the 
intracranial  tension. 


6  loo  J 
prendre 

Pcnctratng    H^our,J,     of    SkJI 
Cj:c    Numbers 
1           ?           3          4-           S          C           7 

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J 

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S^itoliC prCiSurt    O                 DiaitoliC  prtSi^'c    % 

Chart    3. — Blood    pressure    in   penetrating   wounds   of   skull. 

5.  The  Effect  of  Anesthesia  on  the  Blood  Pressure 
Readings  of  Head  Wounds. — It  was  in  regard  to 
answering  this  cjuestion  that  our  attention  was  first 
directed  to  blood  pressure  readings  in  various  wound 
conditions.  We  had  noticed  a  sequence  of  events 
somewhat  as  follows : 

A  man  is  admitted  with  one  of  the  severe  types  of  head 
wounds  associated  with  tearing  of  the  meninges  and  lacera- 
tion of  the  brain;  no  examination  is  made  of  the  blood  pres- 
sure; operation  is  performed  within  an  hour  or  two  following 


15 


••ulmission.  Tn  tlic  later  staKcs  of  the  operation  and  suIjsc- 
(|uently,  a  case,  wliicli  before  f)[)cration  had  appeared  promis- 
ing, now  entirely  alters,  the  pulse  rate  becomes  very  rapid, 
unconsciousness  deepens,  the  respiration  rate  is  greatly 
increased,  the  patient  becomes  bathed  in  the  most  profuse 
perspiration,  the  temperature  usually  falls  to  a  subnormal 
level,  and  death  very  rapidly  supervenes. 

It  was  difficult  to  discover  any  explanation  of  such  a 
rapid  change.  The  time  was  too  short  for  sepsis  to 
be  the  explanation,  the  amount  of  hcmorrhaf:(c  was 
never  sufiicicnt  to  explain  the  condition,  and  the  injury 
itself  was  not  one  that  involved  any  immediately  vital 


BhcJ 

P„,fc,of„<,,    r,c^^J,    ef  SI../I                        '                   1 

Ca,.     f^^b.,. 

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r 
tip 

T"? 

' 

Q             /       \ 

V        6-<5' 

1 

s^,nji<    p.^ss^.t      o 

Chart    4. — Blood    pressure    in    perforating    wounds    of    skull. 

part.'^  We  began  examining  the  blood  pressures  in 
these  cases,  and  from  such  an  examination  we  believed 
we  had  found  the  explanation  of  the  disaster. 

These  are  cases  with  a  blood  pressure  which  is  either 
low  or  unstable.  If  operation  is  performed  during  the 
early  stages  of  the  case,  the  effect  of  the  anesthetic, 
together  with  the  extensive  opening  of  the  skull,  is  such 
as  to  produce  a  very  marked  fall  of  pressure.  The 
level  is  so  low  that  no  further  rise  is  secured,  and  the 
patient  succumbs  to  a  condition  that  clinically  resem- 
bles acute  shock. 

3.  Observations  published  in  a  later  number  of  this  series  (Cannon, 
W.  B. :  Acidosis  in  Cases  of  Shock,  Hemorrhage  and  Gas  Infection, 
p.  47)  show  that  this  condition  was  probably  related  to  a  developing 
ncidnsis. 


16 

As  ail  example  of  tlie  uiistalilo  lyiK'  of  blood  ])rcs- 
surc,  we  have  seen  a  ease  in  which  the  systohc  hlood 
l)r^•^sll^c  before  operation  re<,Mstere(l  1()4  nun.;  taken 
innneihately  after  oi)eration  the  i)ressure  had  fallen  lo 
10  mm.     Death  followed  within  thirty  minules. 

With  a  view  lo  overcoming  the  dan<jjcr,  our  proce- 
dure was  altered  in  two  ways.  If  possible,  operation 
was  delayed  for  twenty-four  and  even  for  forty-eigju 
hours,  until,  l)y  successive  readings,  one  had  assured 
oneself  that  the  pressure  had  acquired  soiue  degree  of 
stability;  the  second  modiilcation  was  that  in  doubtful 
cases  and  in  cases  which  demanded  immediate  opcra- 
tit)n,  the  operation  was  performed  either  with  a  local 
aneslhclic  or  while  the  patient  was  under  the  influence 
of  scopolamin  and  mori)hin.  Since  these  modifications 
were  adopted,  disasters  such  as  we  have  described  have 
not  been  observed/ 

6.  Sinimiary  of  Results  of  Exmnination  of  the  Blood 
Pressure  in  Head  JVouuds. — 1.  Scalp  wounds  show  no 
appreciable  alteration  in  blood  pressure. 

2.  Cases  of  compound  fracture  of  the  skull  with 
dura  intact  show  a  relatively  high  blood  pressure,  aver- 
aging above  140  mm. 

3.  Penetrating  wounds  of  the  skull  with  free  drain- 
age are  generally  associated  with  a  low  blood  pressure 
— from  60  to  112  mm. 

4.  In  perforating  wounds  the  blood  pressure  would 
appear  to  vary  according  to  the  anatomic  distribution 
of  the  wound.  If  the  wound  has  hivolved  the  ventri- 
cles, the  blood  pressure  is  high,  varying  from  130  to 
170  mm.;  if  the  wound  is  more  superficial  and  has  not 
involved  the  ventricles,  the  blood  pressure  is  low, 
resembling  the  class  in  Summary  2. 

5.  The  blood  pressure  subsequent  to  wounds  of  the 
head  is  apt  to  be  unstable.  If  operation  is  performed 
under  general  anesthesia  before  the  blood  pressure  has 
become  stable,  disaster  is  liable  to  ensue.  The  possi- 
bility of  such  an  ill  result  can  be  diminished  by  delaying 
operation  until  the  blood  pressure  has  become  stable  or 
by  performing  the  operation  under  local  anesthesia. 

4.  These  methods  were  employed  before  the  rationale  of  preparing 
patients  for  operation,  as  given  further  on  (Cannon,  W.  B.:  Fraser, 
John,  and  Cowcll,  E.  M. :  The  Preventive  Treatment  of  Wound  Shock, 
p.   9^)    hn(\   been   worked  out. 


17 


I?.     AliOOMINAL     WOUNDS 

Before  an  analysis  is  made  of  the  blood  ];ressure  in 
this  type  of  wound,  it  will  be  of  advantage  to  include  a 
very  brief  summary  of  the  cases,  their  clinical  condi- 
tion and  relative  blood  pressures  (Table  1). 

From  such  a  study  as  the  table  contains,  the  c[Ucslion 
arises :  Can  one  with  any  degree  of  certainty  draw 
deHnite  conclusions  from  the  blood  pressure  in  sup- 
])Osed  wounds  of  the  abdominal  cavity?  We  believe 
that  we  can  with  a  minimum  of  error  draw  certain 
deductions. 

First  there  arc  certain  points  to  be  considered.  Cases 
1  to  20  were  observed  at  a  casualty  clearing  station 
after  a  comparatively  short  journey,  that  is,  within 
from  three  to  six  hours  after  being  wounded.  In 
Cases  21  to  30,  with  the  exception  of  Case  27,  more 
than  ten  hours  had  elapsed  between  receipt  of  the 
wound  and  admission  to  the  casualty  clearing  station ; 
in  these  the  primary  shock  had  abated. 

Patient  27  was  observed  within  six  hours  of  being 
wounded.  Patients  31,  32  and  33  were  seen  at  an 
advanced  dressing  station.  Patients  31  and  32  within 
three  hours  of  being  injured,  and  after  a  long  and 
difficult  carry  over  dangerous  ground,  and  during  a 
bitterly  cold  night.  Patient  23  was  quite  fit  when  seen 
in  the  advanced  dressing  station,  but  very  shortly  after- 
ward suffered  marked  collapse.  Such  a  patient  as  this 
has  been  known  to  walk  a  mile  after  sustaining  a  pene- 
trating wound  of  the  abdomen,  involving  injury  to  the 
small  intestine,  and  showing  during  this  time  a  normal 
blood  pressure  and  pulse.  These  patients  soon  become 
worse,  and  the  collapse  is  then  very  intense. 

The  deductions  we  have  thought  it  justifiable  to 
draw  are  briefly  as  follows : 

1.  In  patients  seen  on  arrival  at  a  casualty  clearing 
station  within  six  hours  of  being  wounded,  if  there  is 
an  intraperitoneal  injury  of  a  hollow  viscus,  the  blood 
pressure  is  low.  In  the  series  of  cases  of  this  descrip- 
tion which  we  examined  the  systolic  pressure  varied 
from  50  to  100  mm. 

2.  When  a  period  of  from  six  to  ten  hours  has 
elapsed,  the  pressure  will  probably  have  risen,  for  the 
primary  wound  shock  is  now  beginning  to  pass  oft' — 
the  rest  on  the  stretchers,  the  warmth  and  the  sedative 
action  of  morphin  are  beginning  to  have  effect. 


TABLE     1.— SUMMARY     OF     ABDOMINAL     CASES 


No.    and    Clinical   Condition 


Wound  of  back;  extra- 
peritoneal wound  of 
colon 

Wound  of  small  intes- 
tine 

Multiple  wounds  of 
small    intestine 

Small  wound  of  ante- 
rior altdominal  wall; 
two  perforations  ot 
stoninch 

Wound  apparently  pi-r- 
forating     alidonicn 

Wound  apparently  piT 
forating     abdomen 

Large    shell     wound     of 
abdomen 
8      Supposed        wounil        of 
alnlominal   cavity 

Four  perforations  in 
small    intestine 

Perforation  of  cecum 
and    transverse   colon 

CI.  S.  W.  apparently 
perforating    abdomen  • 


U     C.    S.    W.    abdomen. 


IJ     C    S.    VV.  abdomen. 


14  Two    small    wounds    of 

small     intestine;     very 
stout    man 

15  (i.    S.    W.    abdomen 


10  C.  S.    VV.    abdomen.. 

17  (..  S.     W.    abdomen. 

18  G.  S.    VV.    abdomen.  . 

19  ("..  S.    VV.    abdomen.  . 

20  Ci.  S.    W.   abdomen.. 

21  B.    W.    abdomen 


22  C.    S.    VV.    abdomen. 

23  C.    S.    VV.   abdomen. 

24  ("..    S.    W.    abdomen. 


Special    Features 


25  B.    W.   abdomen 

26  G.    S.    VV.   abdomen. 


Very    slight    hemorrhage; 

peritoneal      cavity       not 

opened 
licneral    peritonitis;     large 

amount   of   blood 
Large     amount      of      free 

blood 
Moderate        amount         of 

blood    in    peritoneum 


Operation   showed    no   per- 
foration 
No   operation;    recovery... 

Injury  to  liver,  colon  and 

duodenum 
No    perforation     


Large  amount  of  blood  in 
peritoneal    cavity 

(ieneral  peritonitis;  small 
amount    of    blood 

Operation  showed  an  ex- 
traperitoneal wound  of 
rectum 

Nonperforating     


Nonperforating     

Very    slight    hemorrhage.. 


Injury    to    liver;    abdomen 

full    of    blood 
Injury    to    right    kidney... 

Injury    to    left    kidney.... 

Wound    of   liver;    exlreme 

hemorragc 
Injury     to     prostate     anil 

bladder 
Injury    to    liver    


27  G.    S.    VV.    back 

28  G.    S.    VV.    abdomen. 

29  G.    S.   VV.   abdomen. 

30  G.    S.    W.    abdomen. 

31  B.    W.    pelvis 

32  B.    W.   pelvis 

33  G.    S.    VV.   abdomen. 


Extraperitoneal  wound  of 
bladder;  slight  hemor- 
rhage 

l-'our  perforations;  small 
intestine;  about  1  pint 
free    blood 

I'uur  perforations  jeju- 
num and  1  in  colon; 
about  I'/j  pints  of  fre>.- 
blood 

Injury  to  pancreas  and 
spleen;  about  IV2  pints 
of    free    blood 

Simple  perforation  of 
colon;    no    free    blood 

Perforated  spleen,  bruise.! 
kidney  and  colon; 
about  1  pint  of  free 
blood 

Six  perforations;  small 
intestine;  profuse  hem- 
orrhage 

Lacerated  liver  and  kid- 
ney; about  2  pints  of 
free*  blood 

Bruising  stomach;  no 
hemorrhage 

Tear  of  colon  and  small 
intestine 

Observed  in  A.D.S. ;  ex- 
act wound  unknown: 
long  carry  over  the 
open 

Observed  in  A.D.S. ;  prob- 
able small  intestine 
lesion 

Observed  in  A.D.S.;  prob- 
able small  intestine 
lesion 


Blood  Pressure 

90  dias 
120  sys. 

100  sys. 
70  dias. 
85  sys 
60  dias. 
70  sys. 
40  dias. 


128  sy« 

100  dias. 

130  sys. 

100  dias. 

50  sys. 

?  dias. 

150  sys. 

lUU  dias. 

100  sys. 

80  dias. 

110  8ys. 

90  dias. 

125  sys. 
100  dias. 

140  sy.s. 
100  dias. 
138  sys. 
100  dias. 
140  sys. 
95  dias. 

138  sys. 
100  dias. 
140  sys. 
100  dias. 
130  sys. 

90  dias. 
105  sys. 

70  dias. 

90  sys. 

60  dias. 
130  sys. 

90  dias. 
140  sys. 
100  dias. 

120  sys. 
95  dias. 

120  sys. 
93  dias. 


125 
90 


sys. 
dias. 


110  sys. 

80  dias. 

136  sys. 

105  dias. 


50  sys. 
20  dias. 

110  sys. 
85  dias. 

120  sys. 

90  dias. 
120  sys. 

90  dias. 

50  sys. 

30  dias. 


45  sys. 
?  dias. 


125  sys. 
80  dias. 


19 

3.  At  a  period  later  than  ten  liours,  the  pressure 
hegiiis  to  fall  and  a  shocklike  condition  Ijecomcs  evi- 
denced; the  change  is  due  to  sepsis  and  to  loss  of  blood 
(secondary  wound  shock). 

4.  Perforating  wounds  of  solid  viscera  of  moderate 
severity  appear  to  be  associated  with  a  relatively  high 
blood  pressure:  wounds  of  the  liver  and  kidney  often 
exhibit  a  systolic  reading  of  from  130  to  140  mm.,  and 
this  even  in  cases  in  which  the  hemorrhage  is  consid- 
erable. We  have  observed  a  tear  of  the  liver  in  the 
case  of  a  soldier  run  over  by  a  limber,  in  which  the 
systolic  pressure  of  140  was  ^naintained  for  twenty- 
four  hours.  At  the  end  of  this  time  the  pressure  fell 
suddenly  and  the  patient  succumbed. 

5.  Perforating  wounds  of  the  viscera  which  do  not . 
open  into  the  peritoneal  cavity  are  associated  with  a 
practically  normal  blood  pressure,  as  in   Case   1,  an 
extraperitoneal  wound  of  the  colon,  and  Case  11,  an 
extraperitoneal  wound  of  the  rectum. 

6.  Large  wounds  of  the  parietes  are  generally  associ- 
ated with  a  lower  blood  pressure  than  small  wounds, 
even  though  the  former  may  have  produced  much  less 
visceral  destruction  than  the  latter.  This  is  probably 
explained  by  the  fact  that  in  the  former  instance  peri- 
toneal blood  readily  escapes,  while  in  the  latter  the 
hemorrhage  continues  to  be  retained. 

We  have  made  several  observations  regarding  the 
effect  on  the  blood  pressure  of  opening  the  peritoneal 
cavity.  Briefly,  we  found  that  if  the  abdominal  cavity 
contained  a  large  amount  of  blood,  there  was  a  very 
rapid  fall  of  pressure  as  soon  as  the  peritoneal  cavity 
was  opened,  and  the  blood  allowed  to  escape.  If,  on  the 
other  hand,  the  abdominal  cavity  did  not  contain  much 
blood,  the  opening  of  the  abdomen  was  followed  by  a 
temporary  rise  in  blood  pressure  by  as  much  as  20  mm. 
After  ten  minutes  the  blood  pressure  fell  to  slightly 
below  the  figure  that  it  registered  before  operation. 

C.     CHEST     WOUNDS. 

A  summary  of  chest  cases  is  given  in  Table  2. 

From  these  readings  there  are  a  few  conclusions  that 
may  be  drawn : 

1.  Large  open  wounds  of  the  chest  with  free 
entrance  and  exit  of  air  are  accompanied  by  a  profound 
fall  of  blood  pressure ;  this  is  evidenced  in  Case  9. 


20 


2.  Patients  with  niiconiplicatod  closed  wounds  of  the 
chest  who  arrive  at  the  casuaUy  cleariiij;  station  well 
cared  for  show  normal  pressure. 

3.  When  severe  internal  heniorrha<i[e  has  occurred 
and  the  patient  has  been  exposed  to  the  cold  for  some 
hours,  or  when  infection  has  become  established,  hypo- 
tension is  present  and  progressive. 

TABLE    2.— SUMMARY     OF     CHEST     CASES 


No.    and    Clinical    Condition 


10 


C;.S.W  Kick     and 

(penetrating). 
G.S.W.  chest    wall 
G.S.W.  chest 


chest 


ing) 
G.S.W.  chest 
ing) 


(penetrat- 
(penctrat- 
(penetrat- 


es. W.  chest 

ing) 
G.S.W.  chest 
G.S.W.  chest 

ing) 

G.S.W.  chest  wall    

G.S.W.  chest      (penetrat 


wall     .  . .  . 
(penetrat 


ing) 
G.S.W.  chest 

ing) 
G.S.W.  chest 

ing) 

chest 


(perforat 
(perforat- 
(penelrat 
(penetrat 
(penetrat- 


G.S.W 
ing) 

G.S.W.  chest 
ing) 

G.S.W.  chest 
Jng) 

B.W.  chest  (perforating) 

G.S.W.  chest      (penetrat- 
ing) 

Shell    wound    chest 

G.S.W.    chest    .... 

G.S.W.    chest    .... 


20     G.S.W.      chest      (open 
pneumothorax) 


Special    Features 


Lower  chest    

Non-perforating    

Lower   chest    

Upper   chest    

Upper   chest    

Non-perforating    

Upper    chest    

Non-perforating     

Very     large    wound     upper 

chest 
Multiple  wounds   

Lower   chest   involving   dia 

phragni 
Right    upper  chest 

Lower  chest   

Multiple    wounds    

Upper   chest    

Surgical    emphysema    

Penetrating  upper  chest  . 
Very  small  hemothorax ... 
Lower  chest,   injuring  liver 

and    diaphragm 
Observed    in    A.D.S. 


Blood 
Pressure 


120—  90 

138—100 
130—  90 

90—  60 

90—  60 

136—  90 
98—  80 

128—100 
38—   ? 

110—  90 

138—  90 

105-  80 

130—  95 

no—  90 

170—100 
130—  80 

120—  90 
130—  85 
138—105 

70—  "35 


4.  Patients  whose  chest  wounds  arc  complicated  by 
perforation  or  laceration  of  the  diaphragm  behave  in 
the  same  way  as  Class  2  or  3. 

The  high  pressure  recorded  in  Case  15,  under  the 
influence  of  rest  and  morphin,  rapidly  dropped  to  120, 
and  remained  so  for  the  remainder  of  the  time  the 
patient  was  under  observation.  In  Case  16  the  press- 
ure gradually  dropped  with  the  onset  of  a  septic 
pericarditis. 


21 


D.      MUI/I'II'IJ-;     WOUNDS     AND     WOUNDS     (Jl-' 
lOXTKKMlTIKS 

( )iil  of  a  larj^^c  number  of  ol)S(;rvalions  wc;  have 
selected  a  siininiary,  representative  of  different  types  of 
wounds  (Table  3). 

TABfJ-:     3.— SIJMMAKY     Ol'     CASES 


No 

and    Clinical    Condition 

Special     l-'eaturcs 

Blood 
Pressure 

(].S.W   Fractures — 

T,owER  Extremity — 

1 

C.S.W.  fraoture — both 
thighs 

Moderate    hcnuirrhage     .... 

100—  85 

2 

G.S.W.    fracture— tihia.  . 

Moderate   hemorrhage    .... 

110—  90 

3 

G.S.W.    fracture— botli 

legs 
G.S.W.    fracture — knee.  . 

Severe    hemorrhage    

68—  SO 

4 

Severe    hemorrhage     

30— 

5 

G.S.W.    fracture— tiljia.  . 

Apparently      slight      hemor- 
rhage 

70—  50 

6 

G.S.W.    fracture— tibia.  . 

Severe     injury,     but     slight 
hemorrhage 

143-100 

7 

G.S.W.   fracture— both 
legs 

Moderate    hemorrhage    .... 

96—  80 

8 

(;.S.W.    fracture— leg    .  . 

.Severe    hemorrhage     

100—  72 

') 

(J.S.W.    fracture — femur. 

No    hemorrhage    

160—10 

10 

G.S.W.    fracture — femur. 

Moderate   hemorrhage    .... 

115— 

11 

G.S.W.    fracture — femur. 

Moderate    hemorrhage    .... 

112— 

IJ 

G.S.W.    fracture — femur. 

Seen  in  A.D.S.   (two  hours' 
carry) 

98—  70 

13 

G.S.W.    fracture— tibia.  . 

Considerable     hemorrhage.  . 

90—  60 

14 

G.S.W.    fracture — tibia.  . 

Hemorrhage    and    sepsis... 

65—  30 

15 

G.S.W.    fracture — fibula. 
G.S.W   Fracture- 
Upper    Extremity — 

Seen  in  A.D.S. ;  much  pain 

140— 

« 

16 

G.S.W.     fracture— hu- 
merus 

Slight    hemorrhage    

148—100 

17 

G.S.W.    fracture — fore- 
arm 

Severe    hemorrhage     

103—  80 

18 

G.S.W.   fracture— hu- 
merus 

Severe    hemorrhage     

105—  80 

19 

G.S.W.    fracture— fore- 
arm 
Face   Wounds —   . 

Severe    hemorrhage     

105—  80 

20 

Severe  face  wound    .... 

Severe    hemorrhage     

114—  8n 

;M 

Face   wound   and   jam... 

128     100 

t:>. 

Severe    hemorrhage     

138—100 

Simple   Flesh   Wounds- 

-'3 

Flesh   wound — arm    

Flesh    wound — leg    

Flesh   wound — arm    

Multiple   Wounds — 

140     100 

?A 

170     100 

:?=; 

138       90 

26 

Multiple    wounds — legs.  . 

Slight    hemorrhage    

110—  90 

■s/ 

Multiple   wounds    

Slight    hemorrhage    

128— lOS 

2S 

Multiple    wounds    

Slight    hemorrhage    

118—  98 

29 

Multiple    wounds    

Slight    hemorrhage    

100—  75 

30 

Multiple    wounds    

Slight    hemorrhage    

100—  80 

1.  Compound  fracture  of  the  lower  extremity, 
seen'  in  the  casualty  clearing  station,  was  generally 
associated  with  a  considerable  fall  in  blood  pressure, 
more  marked  when  the  fracture  affected  the  region  of 
the  knee  joint.     Undoubtedly  the  blood  pressure  read- 


22 

ing  was  largely  aftcctcd  by  the  amount  of  hemorrhage 
that  had  occurred.  One  finds  in  such  a  case  as  Case 
6 — a  severe  compound  fracture  of  the  tibia  with  a  very 
small  amount  of  hemorrhage — a  systolic  blood  pressure 
registered  of  143.  On  the  other  hand,  Case  -i — a  com- 
]iound  fracture  in  the  neighborhood  of  the  knee, 
accompanied  by  severe  hemorrhage — registered  a  sys- 
tolic blood  pressure  of  only  30. 

2.  One  might  expect  compourid  fracture  of  the 
upper  extremity  to  affect  the  blood  pressure  less  than 
fracture  of  the  lower  extremity.  We  were  surprised 
to  tind  the  comparatively  low  pressure  which  compound 
arm  fractures  generally  registered ;  the  remarks  that 
are  made  as  regards  hemorrhage  in  wounds  of  the 
lower  extremity  equally  apply  in  this  connection. 

3.  In  face  wounds  there  is  not  much  alteration  of  the 
blood  pressure,  unless  there  is  an  associated  con.pound 
fracture  of  the  face  bones,  when  the  pressure  is  gen- 
erally lowered. 

4.  Multiple  wounds  of  the  body  and  extremities 
were  accompanied  by  a  considerable  fall  in  blood 
pressure. 

Blood    Pressure   Readings    as   Studied    Subse- 
•  QUENT   TO   Various    Intravenous 

Transfusions 

a.    physiologic   sodium    ciilorid 

For  many  years  the  intravenous  infusion  of  physio- 
logic sodium  chlorid  solutions  (0.9  per  cent,  sodium 
chlorid)  has  been  extensively  used  in  shock  and  in  col- 
lapse after  hemorrhage.  We  confess  we  have  been 
greatly  disappointed  with  the  results  obtained,  and 
blood  pressure  readings  confirm  the  clinical  disappoint- 
ments that  we  have  experienced.  Chart  5  is  typical  of 
many  that  we  have  recorded. 

Private  C.  M.  was  admitted  with  a  simple  fracture  of  the 
right  humerus  and  a  severe  shell  wound,  involving  the  right 
knee.  The  wound  was  sustained  at  9  p.  m.,  and  he  was 
admitted  to  the  advanced  dressing  station  by  10  p.  m.  He  was 
then  in  a  collapsed  and  pulseless  condition.  He  was  treated 
by.  the  application  of  warmth,  and  half  a  pint  of  physiologic 
sodium  chlorid  solution  was  given  subcutaneously  in  each 
flank.  By  1  a.  m.,  that  is,  three  hours  after  admission  to  the 
advanced  dressing  station,  his  condition  was  said  to  have  so 


23 


far  improved  as  to  warrant  liis  removal  to  tlic  casualty  clear- 
ing station.  On  admission  to  the  casualty  clearing  station  he 
was  found  to  be  extremely  collapsed;  a  radial  pulse  coidd 
only  occasionally  he  felt;  the  systolic  hlood  pressure  harely 
registered  30  mm.  of  mercury;  no  diastolic  pressure  was 
read.  Two  pints  of  physiologic  sodium  chlorid  solution  were 
administered  intravenously;  immediately  the  systolic  pressure 
rose  to  75  mm.,  Iiut  after  a  period  of  about  twenty  minutes  it 


Sy;.  folic 

9/cci/ 
Pressure 

°            c 

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J 

Chart    5. — Systolic    blood    pressure    with   administration    of 
physiologic    sodium    chlorid    solution. 


pints   of 


rapidly  began  to  fall,  and  within  one  hour  after  the  adminis- 
tration it  had  fallen  actually  to  a  lower  level  than  before  the 
infusion  had  been  given.  There  was  no  further  rally,  and 
^eath  occurred  about  three  hours  later. 

The  blood  pressure  (systolic)  readings  are  graph- 
ically recorded  in  Chart  5. 

It  would  appear  that  the  introduction  of  the  physi- 
ologic sodium  chlorid  solution  induced  a  condition  of 


24 

liydrtiuic  plotliora — tb.at  is.  a  ililiuion  and  increase  in 
the  total  volnnie  of  tlie  blood.  The  kiilneys,  the  skin 
and  the  lymph  channels  excrete  the  excess  of  fluid, 
there  is  profuse  perspiration,  and  presently  the  blood 
is  actually  less  in  bulk  and  more  concentrated  than  it 
was  before.  This  is  in  kecpinjj  with  the  observations 
of  Lazarus  Barlow,  who  has  shown  that  the  specific 
j^^ravity  of  the  blood  at  first  falls  from  \.0(A  to  1.054, 
anil  later  rises  to  1.067;  in  other  words,  there  is  at  lirst 
a  dilutit)n  of  ihc  lilood  and  afterward  an  actual  con- 
centration. 

n.    ringer's  solution  and  its  modifications 

The  fluid  known  as  Ringer's  solution  has  the  follow- 
ing composition :  sodium  chlorid,  0.9  per  cent. ; 
potassium,  0.0.^  j^er  cent. ;  calcium,  0.02  per  cent.,  and 
a  trace  of  sodium  carbonate. 

In  place  of  this  we  have  been  using  a  hypertonic 
solution,  as  recommended  in  a  ])ul)lication  of  the  Med- 
ical Research  Committee,  and  constituted  thus:  sodium 
chlorid,  2  gm. ;  potassium  chlorid,  0.05  gm.;  calciuui 
ihlorid,  0.05  gm. ;  water,  100  c.c. 

From  its  intravenous  use  we  have  obtained  satisfac- 
tory results,  and  the  clinical  history  and  blood  pressure 
chart  of  a  typical  and  successful  case  is  recorded. 

Sergeant  A.,  R.  F.  A.,  was  admitted  with  a  severe  shell 
wound  of  tlie  pelvis,  injury  to  the  I)ladder  and  prostate  and 
profuse  bleeding.  On  admission  the  respective  pressures 
were:  systolic,  90  mm.;  diastolic,  60  mm.  Immediate  opera- 
tion was  necessary.  Subsequently  there  was  intense  col- 
lapse— the  systolic  pressure  registered  only  25  mm.,  the 
diastolic  pressure  about  20  mm.  Two  pints  of  hypertonic 
solution  were  administered  intravenously,  and  in  immediate 
response  the  pressures  rose,  respectively,  to  1(X)  mm.  and 
80  mm.  One  hour  later  they  had  fallen  to  65  mm.  and  50  mm. 
Thereafter  the  pressure  steadily  began  to  rise,  and  six  hours 
later  it  had  reached  100  mm.  and  80  mm. 

The  readings  were  maintained,  and  an  eventual  recovery 
was  made. 

Chart  6  graphically  illustrates  the  blood  pressure 
(systolic)  readings  in  this  case. 

c.     colloidal    solution 

At  the  suggestion  of  Prof.  W.  Bayliss  and  Col.  Cuth- 
bert  Wallace,  A.  M.  S.,  we  have  used  intravenously  in 


25 

cases  of  hy])()tcnsioii  due  to  profound  shock  and  the 
toxemia  of  gas  gangrene  a  solution  of  gum  acacia. 

We  had  In'st  arrived  at  the  formula  we  have  used 
with  undermentioned  cases,  when  the  rci}ort  of  the 
Medical  Research  Committee  was  published,  March 
24.  The, formula  we  employ  is  as  follows:  calcium 
chlorid  (B.  P.),  0.075  gm. ;  sodium  chlorid,  1.325  gm. ; 
gum  acacia,  2  gm. ;  water,  100  c.c.  A  double  strength 
solution  is  conveniently  made  and  kept  in  sterilized 
bottles — sterilization   should   be   repeated   each    week 


s.pio/,.- 

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Chart  6. — Systolic    blood   pressure    with   administration    of   2    pints    of 
hypertonic    solution. 

This  solution  is  made  up  as  follows :  calcium  chlorid 
(B.  P.),  13  grains;  sodium  chlorid,  232  grains;  gum 
acacia,  350  grains ;  water,  1  pint. 

In  comparison  with  the  formula  recommended  by  the 
Medical  Research  Committee,  we  give  less  sodium 
chlorid  and  more  calcium  chlorid,  while  we  omit  the 
potassium  salt  entirely.  With  this  solution  good  results 
have  been  observed  when  from  15  to  20  or  even  30 
ounces  of  the  solution  are  given  intravenously.     The 


26 


solution  was  fjivcii  slowly  at  the  rate  of  5  ounces  in  five 
minutes,  and  its  heat  maintained  at  a  temperature  of 
about  120  F.  in  the  reservoir.  It  passed  from  the 
reservoir  through  a  compte-gouttes  chamber  and 
entered  the  body  by  means  of  a  small  glass  cannula  tied 
into  cephalic  or  saphenous  veins.  The  infusion  was 
repeated  after  twelve  or  twenty-four  hours,  if 
necessary. 


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Chart    7. — Systolic   blood   pressure   with  administralion   of  an    infusion 
of   30  ounces  of  gum   solution. 

Chart  7,  taken  from  Case  27,  is  added  to  illustrate 
graphically  the  blood  pressure  (systolic)  response  in  a 
successful  case. 

From  a  study  of  the  cases  quoted  above  it  may  be 
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When  it  has  been  ])ossib]e  to  remove  the  source  of 
infection,  tlie  rise  of  pressure  is  ])roj:(rcssive  in  the  sub- 
sequent twenty-four  iiours,  riiul  the  jjressurc  is  main- 
tained during  the  early  critical  days  of  convalescence. 

In  Case  27  the  patient  was  admitted  apparently  morihund. 
After  an  hour's  rest  with  warmtli  and  rectal  glucose-saline 
injection,  he  was  submitted  to  laparotomy;  there  were  about 
2  pints  of  free  blood  in  the  peritoneal  cavity,  and  six  perfora- 
tions of  the  intestine   required   suture.     Intravenous   infusion 


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Chart  8. — Systolic  blood   pressure  with   fifteen   minutes  of  direct   blood 
transfusion. 

of  gum  was  commenced  with  the  operation.  When  the  opera- 
tion was  completed,  thirty  minutes  later,  the  pressure  had 
risen  to  80  mm.,  and  a  fair  pulse  was  palpable  at  the  wrist. 
The  following  day  the  pressure  was  120  mm. ;  it  rose  later  to 
140  mm.,  and  remained  at  this  figure  during  an  uneventful 
convalescence. 


D.     DIRECT     BLOOD     TRANSFUSION" 

We  have  had  an  opportunity  of  observing  in  several 
cases   the    results   of    direct   blood   transfusion.     The 


30 

transfusion  was  necessary  on  account  of  severe  arterial 
hcniorrhaj;e,  and  was  carried  out  by  the  direct  nietliod. 
as  suggested  by  Basset  and  Fullerton.  The  time  of  the 
transfusion  varied  from  fifteen  to  twenty-two  minutes. 
It  is  (hfficult  to  estimate  with  any  degree  of  exactness 
how  much  blood  was  transferred  during  these  respec- 
tive jx'riotls,  but  we  calculate  roughly  that  from  500  to 
700  c.c.  would  be  about  the  proper  estimate. 

The  following  are  the  notes  and  the  blood  pressure 
chart  of  one  of  these  cases: 

Liculenant  ,  admitted  with  a  severe  shell  wound  of  the 

kfl  tliiyh  :  tlie  femoral  vessels  were  lorn;  no  touniitiuct  had 
heen  applied,  and  the  patient  was  practically  murihund  from 
loss  of  blood. 

After  the  local 'wound  had  lieen  dealt  with  a  donor  was 
secured,  and  direct  transfusion  of  blood  begun.  Transfusion 
was  continued  for  fifteen  minutes.  Clinically  there  was  a 
most  dramatic  imjjrovement,  and  within  the  course  of  a  few 
hours  the  pulse  rate  had  fallen  from  150  to  95.  The  systolic 
blood  pressure  on  admission  was  very  diflicult  to  estimate ; 
but  it  was  estimated  at  about  20  mm.  Before  the  transfusion 
had  been  completed  it  rose  to  115;  one  hour  later  it  had  fallen 
to  100.  At  the  end  of  another  hour  it  had  risen  to  110,  and 
about  this  level  it  remained  for  the  first  twenty-four  hours; 
thereafter  it  attained  and  remained  at  a  level  of  about  120. 

The  blood  ])rcssure  readings  were  as  shown  on 
cliarts. 

E.      GLUCOSE     SOLUTION 

We  have  no  records  of  blood  pressure  readings  fol- 
lowing the  infusion  of  hypertonic  glucose  solutions. 

F.     OTHER     MEASURES 

From  time  to  time  various  drugs  are  advocated,  such 
as  pituitary  solution,  epinephrin,  cafTein,  camphor,  etc. 
/\t  present  there  is  not  sufficient  evidence  to  show  that 
one  of  these  drugs  takes  precedence  over  the  others. 

G.    CONCLUSIONS 

1.  In  cases  of  profound  shock  accompanied  by  loss 
of  blood,  excellent  results  are  obtained  from  direct 
blood  transfusion. 

2.  Injection  of  the  calcium  hyjiertonic  gum  solution 
will  produce  an  immediate  rise  of  pressure  in  hemor- 
rhage cases  or  cases  of  hypotension,  complicated  by 
toxemia. 


31 

This  rise  may  tide  ihc  patient  throiij:(li  an  operation. 
If  the  source  of  the  infccli(jn  is  rcniovefl,  the  tension 
will  remain  supported. 

3.  In  milder  cases  of  shock  and  hemorrhage,  infu- 
sion with  hypertonic  saline  is  useful. 

4.  Results  obtained  after  infusion  with  physiologic 
sodium  chlorid  solution  have  been  unsatisfactory. 

Pressure    Observations   in    the    First    Week 
OF    Convalescence   as   an   Aid   to   Prog- 
nosis   AND    to   Treatment 

An  extensive  niwnber  of  pressure  charts  have  been 
collected,  showing  the  behavior  of  the  tension  not  only 
before  and  during  operation,  but  also  in  the  first  week 
of  convalescence.  We  have  thus  a  series  of  controls 
that  show  such  complications  as  the  onset  of  sepsis  or 
gas  gangrene,  and  illustrate  the  subsequent  history  of 
intravenous  infusion  for  shock,  hemorrhage  and  tox- 
emia. 

An  uncomplicated  wound  running  a  favorable  course 
shows  a  steadily  maintained  blood  pressure.  With  the 
onset  of  gas  gangrene  or  sepsis  there  is  a  sudden  fall 
in  pressure  (Case  13).  Occasionally  a  long  sustained 
hypotension  pressure  reading  may  be  observed  (Cases 
9  and  12),  even  though  the  patient  is  quite  well  and  no 
sepsis  is  present. 

A  steadily  rising  or  maintained  high  pressure  read- 
ing, even  in  a  severe  wound,  may  be  taken  as  a  most 
favorable  prognostic  sign  (Cases  2  and  6). 

We  acknowledge  our  indebtedness  to  Col.  Cuthbert 
Wallace,  C.  M.  G.,  A.  M.  S.,  and  to  Professor  Bayliss,  for 
repeated  suggestions  and  assistance;  to  Lieutenant-Colonel 
Winder,  R.  A.  M.  C,  and  Lieut.-Col.  A.  H.  Safford, 
R.  A.  M.  C„  for  permission  to  investigate  the  subject;  to 
Lieut.-Col.  T.  R.  Elliot,  R.  A.  M.  C,  and  the  Medical 
Research  Cornmittee  for  the  various  instruments  which  were 
employed  in  the  investigation. 


SOME     ALTERATIONS     IN     DISTRIBUTION 

AND     CHARACTER    OF    BLOOD     IN 

SHOCK    AND     HEMORRHAGE 

W.    B.    CANNON,    M.D.     (BOSTON) 

Captain,   M.    R.   C,    U.    S.    Army 

JOHN     FRASER,     M.D. 

Captain,    R.    A.    M.    C. 
AND 

A.    N.     HOOPER 

Captain,   R.    A.    M.    C. 
FRANCE 

Introduction 

Tlic  importance  .of  traumatic  shock  as  a  serious 
comiilicating  factor  of  wounds  and  of  sur^^ical  opera- 
tions, and  its  mysterious  nature,  have  coml)ined  to 
stimulate  investigation  into  its  causes  and  into  methods 
of  deahng  with  it.  That  investigation  of  shock  has 
heen  (hfficult  and  baffling  is  incHcated  by  the  number 
and  variety  of  the  theories  put  forth  to  account  for  it. 
The  (hfiicuUies  lie  not  only  in  the  obscure  character 
of  shock  itself,  but  also  in  complications  introduced 
by  attendant  conditions,  such  as  hemorrhage  and  sej)sis. 
Under  these  circumstances  the  most  hopeful  mode 
of  obtaining  insight  is  by  gathering  as  many  facts  of 
observation  as  possible,  with  the  chance  tliat  the  facts 
may  suggest  the  nature  of  the  process  or  processes 
that  are  occurring. 

The  observations  of  Sherrington  and  Copeman'  that 
intraperitoneal  operations  on  animals  raise  the  specific 
gravity  of  the  blood,  the  confirmatory  studies  of  Cob- 
bett-  and  also  of  Vale,^  indicating  a  concentration  of 
the  blood  in  conditions  that  induce  shock,  and  the 
experiments  of  Mann,'  showing  that  the  amount  of 
blood  stagnant  in  the  tissues  of  an  animal  in  shock 
may  be  more  than  50  per  cent,  above  the  amount  in 
the  normal  animal — all  these  evidences  indicate  that 

1.  Slu-rrington   and   Copeman:  Jour.   Physiol.,   1893,  14,  83. 

2.  Colibett:  Shock,  in  Allbutt:  System  of  Medicine,  London,  1897,  3. 

3.  Vale:  Med.  Rcc.,  New  York,  1904,  46,  325. 

4.  Mann:   Surg.,  C.yncc.   and  Obst..   1915,  65,   380. 


33 

examination  of  the  Ijlood  might  yield  significant  facts. 
Warfare  provides  shock  cases  in  hirgc  numhers.  At  a 
casualty  clearing  station,  where  only  the  most  severely 
wounded  were  admitted  for  treatment,  wc  have  had 
an  unusually  favorahle  opportunity  to  study  their  con- 
ditions, and  at  Col.  Cuthbert  Wallace's  suggestion 
we  undertook  observations  on  the  physical  features 
of  the  l,)lood  in  these  cases.  The  present  account  is 
based  on  records  of  observation  in  ninety-eight  cases 
of  shock  and  hemorrhage,  and  in  fourteen  control 
cases. 

The  routine  examination  consisted  of  a  count  of  the 
red  blood  corpuscles  (referred  to  henceforth  as  "red 
count"),  estimation  of  the  hemoglobin  by  use  of  the 
Haldane  hemoglobinometer,  and  determination  of  the 
percentage  of  cori)uscles  in  the  blood,  either  by  capil- 
lary hematocrit  or  by  larger  graduated  tubes,  if  the 
amount  of  blood  permitted.  When  desirable  to  keep 
the  blood  for  some  time  unclotted,  potassium  oxalate 
crystals  were  added  in  minimal  amount;  but  when 
this  was  done,  the  hematocrit  readings  were  made  at 
once  in  order  to  avoid  any  change  of  corpuscle  volume 
through  the  action  of  the  added  salt. 

Although  the  blood  examinations  were  made  in  a 
routine  manner,  we  have  kept  in  mind  certain  ques- 
tions to  which  we  hoped  to  find  more  or  less  definite 
answers : 

1.  Are  these  changes  in  certain  physical  features  of 
the  blood  peculiar  to  cases  of  shock  and  of  hemor- 
rhage ? 

2.  Are  there  typical  postoperative  blood  changes  in 
these  cases  ? 

3.  What  are  the  effects  on  the  blood  of  intravenous 
infusions? 

4.  May  the  data  provided  by  blood  examinations  be 
helpful  in  prognosis? 

We  propose  to  present  and  consider  our  results 
under  these  headings. 

The    Blood    Changes    Peculiar    to    Shock 

In  discussing  the  blood  changes  in  shock  it  will  be 
desirable  to  distinguish  between  cases  of  severe  or 
extreme  shock,  as  seen  at  the  casualty  clearing  station, 
and  those  of  moderate  character.    To  some  extent  the 


34 

judgment  of  these  coiulitions  is  based  on  an  extensive 
clinical  experience  of  one  of  us  (J.  F.)  in  connection 
with  blood  pressure  tletcnninations  in  shock  cases.' 
Combined  with  this  clinical  judgment  were  pressure 
readings.  Roughly,  the  moderate  cases  had  a  systolic 
pressure  over  90  mm.  of  mercury,  and  the  severe 
cases  not  over  70  mm. 

The  first  noteworthy  characteristic  of  the  blood  in 
shock  is  a  high  capillary  red  count.  In  Chart  1  is 
presented  the  red  count  in  twenty-seven  cases  classilicd 
as  severe  traumatic  shock.  In  all  but  eleven  of  the 
cases  the  count  was  6  million  corpuscles  or  higher, 
and   in   ei?ht  cases   it  was  more   than   7  million   cor- 


Chart   1. — Red   corpuscle  counts  in   twenty-seven  cases  of   severe   shock. 

puscles."  When  hemorrhage  as  a  complicating  factor 
tending  to  reduce  the  blood  count  is  considered,  these 
high  counts  are  striking.  They  indicate  that  in  shock 
a  concentration  of  the  blood  occurs,  at  least  in  the 
superficial  capillaries. 

Whether  or  not  the  concentration  found  in  capillary 
blood  is  true  of  all  the  blood  can  be  determined  by 
counting  capillary  and  venous  samples  taken  at  the 
same  time.  When  this  is  done,  a  more  or  less  marked 
discrepancy  between  the  two  is  revealed.  The  capillary 
samples  have  been  taken  from  widely  separated  parts 
of  the  body — from  the  lobe  of  an  ear,  from  a  finger 
or  from  a  toe ;  the  venous  samples  from  an  arm  vein. 
In  Chart  2  are  plotted  the  observations  in  seven  cases 

5.  Frascr,  John,  and  Cowell,  E.  M.:  Clinical  Study  of  Blood  Pressure 
in  Wound   Conditions,  p.  9. 

6.  These  counts  were  made  by  means  of  a  Thoma  instrument  made 
by  Hawksley;  it  was  compared  with  a  Thoma-Zeiss  instrument,  and  a 
difference  of  only   10,000  corpuscles  in   5,000,000  was  found. 


35 

of  severe  shock,  four  cases  of  moderate  shock,  and 
five  cases  in  which  no  shock  was  present.  The 
strikingly  higher  capilkiry  than  venons  red  count 
in  the  severe  cases,  amounting  frequently  tc;  2  million 
corpuscles,  was  reduced  in  the  moderate  cases,  but 
even  in  these  the  dilTcrence  is  still  nearly  a  million 
corpuscles  per  cubic  millimeter.''  In  the  final  group 
of  cases,  in  which  no  shock  was  present,  the  cajjillary 
count  was  uniformly  slightly  higher  than  the  venous, 
but  as  compared  with  the  results  in  the  other  two 
groups,  the  difference  is  neglible.  These  observations 
have    been    made    independently    by    two    observers. 


Corpusc'ei 
Millions 

Severe  ShocU 
1       2       3       4       S       6       7 

MoJ,!,dte  ShocU 
8       9       10      II 

No  ShocU 
12       13      /♦       IS      16 

8 

7 
6 
S 
4 

\               /  \fioDi7/arLf    Count' 

/   V                  o 

A           1           ^                   1      ^ 

^=*^^.o-<^ 

Venous    Coun-f 

^^^^ 

^ 

Chart  2. — Comparison  of  red  counts,  capillary  and  venous,  in  cases  of 
severe   and   moderate   shock,   and   in   patients   without   shock. 


Biirker^  states  that  in  the  same  person  blood  from 
the  finger  tip  and  ear  is  the  same  wdth  reference  to 
hemoglobin  content  and  red  counts  within  an  error 
of  1  per  cent.,  and  that  blood  from  an  elbow  vein, 
when  flowing  free,  is  indistinguishable  from  that  of 
the  ear  or  finger.  Control  observations  made  by  us 
on  normal  individuals  did  not  reveal  greater  differences 
than  3  per  cent,  between  capillary  and  venous  counts  ; 
and  comparative  counts  of  capillary  and  venous  blood 
taken  before  rising  from  bed  in  the  morning  proved 
that  the  discrepancy  is  not  due  merely  to  inactivity. 

7.  Capt.  E.  Emerys-Roberts  has  reported  to  us  verbally  that  he  has 
made  similar  observations  in  cases  of  shock,  and  recently  the  results 
have  been  confirmed   by  Capt.   Eric  Taylor. 

8.  Burker:  Tigerstedt's  Handbuch  der  Physiologischen  Methodik, 
Leipzig,    1912,   3,   Part   5,   p.   4. 


36 

I'roiii  the  forcgoiiii:^  consiilcrations  it  is  clear  that  the 
(htVerence  between  cai)illary  and  venous  rcil  counts 
varies  roughly  with  the  ilegree  of  shock,  and,  since 
the  venous  count  is  approximately  normal,  the  difi'er- 
ence  is  due  to  concentration  of  the  blood  or  stagnation 
of  corpuscles  in  the  capillaries. 

In  all  ])robability  the  low  temperature  typical  of 
patients  in  shock  is  an  important  factor  in  producing 
the  increased  corjjuscular  content  of  the  ca])illaries. 
It  is  known  that  blood  drawn  from  a  cold  finger  con- 
tains a  larger  number  of  corpuscles  in  a  given  volimie 
than  that  drawn  from  the  same  linger  after  it  has 
been  warmed."  In  cases  of  shock,  simultaneous  counts 
of  venous  blood  and  sami)les  from  capillaries  of  the 
ear,  the  finger,  and  the  mucous  membrane  of  the  mouth 
show  signilicant  diflerences.  In  one  case  of  slight 
shock  the  venous  red  count  was  5,360,000,  the  ear  ami 
linger  capillary  counts  6,450,000  and  6,280,000,  respec- 
tively, and  the  buccal  count  5,600,000.  The  capillaries 
of  the  mouth,  less  exposed  to  loss  of  heat  than  those 
of  the  skin,  contained  blood  nearer  the  venous  blood 
in  concentration  than  did  those  of  .the  skin,  but  stil! 
indicating  stasis. 

When  the  capillary  stagnation  has  become  estab- 
lished, it  does  not  promptly  disappear.  We  have  seen 
a  patient  who  had  recovered  from  severe  shock,  but 
whose  hands  from  wrist  to  finger  tips,  in  spite  of 
being  warmed,  were  still  bluish-gray  with  stagnant 
blood. 

Hematocrit  determinations  of  the  volume  per  cent, 
of  corpuscles  in  capillary  and  venous  blood  have  also 
been  made.  In  each  instance  duplicate  tests  were 
carried  out  in  order  to  avoid  any  error  that  might  aris(; 
from  adhesion  of  blood  to  the  wall  of  the  capillary 
tube.  The  results  confirmed  the  discrepancy  between 
capillary  and  venous  sam])les  that  was  found  in  the 
counts.  The  capillary  corpuscle  volume  was  greater 
than  the  venous  by  amounts  ranging  from  12  to  33 
per  cent. 

The  difference  between  capillary  and  venous  blood 
in  shock  was  further  confirmed  by  hemoglobin  deter- 
minations. In  cases  thus  compared,  the  capillary 
hemoglobin  readings  exceeded  the  venous  by  amounts 
ranging  from  6  to  29  per  cent.     In  the  case  cited  at 

9.  Gulland  and  Goodall:  The  Blood,  London,  1914,  p.  61. 


37 

the  end  of  the  second  j)ui"igrai)h  a1)Ovc,  the  hcmo^1ol)in 
reading  of  the  blood  in  the  still  abnormal  fmgers  was 
114  per  cent.,  that  of  llic  recovered  capillaries  of  the 
ear,  104  per  cent. 

A  comparison  of  sonic  of  the  lilood  counts  and 
hematocrit  and  hemoglobin  determinations  in  our  cases 
is  ])resentcd  in  'J'able  1. 

As  mentioned  before,  shock  is  frequently  compli- 
cated by  hemorrhage.  In  these  conditions  the  capillary 
red  count  may  be  low,  but  when  compared  with  the 
venous  red  count  the  discrepancy  between  the  two  at 


TAT3LR    ].— VENOUS    AND    CAPILLARY    RED    COUNTS,    WITH 

HEMATOCRIT    AND    HEMOGLOBIN    READINGS,    IN    SOME 

CASES    OF    LOW    BLOOD    PRESSURE 


Blood 

Red  Counts 

Hemato- 

Hemo- 

Initials* 

Pressure 

(in  millions) 

crit 

globin 

Dias- 

Sys- 

Venous 

Capil- 

Venous 

Capil- 

Venous! Capil- 

tolic 

tolic 

lary 

lary 

lary 

P.   K. 

34 

52 

3.8 

5.6 





_ 

— 

A.    S. 

38 

62 

4.5 

6.4 

30 

41 

— 

— 

E.  G. 

40 

64 

6.2 

8.5 

30 

47 

88 

113 

P.  H. 

(near 

death) 

4.0 

6.0 

31 

43 

— 

— 

D.  H. 

48 

64 

4.2 

5.5 

37 

41 

80 

95 

S.    D. 

48 

72 

4.7 

5.3 

30 

35 

75 

84 

W.  W.  T. 

t 

60 

5.3 

6.4 

— 

— 

■  92 

98 

w.  C. 

58 

76 

4.5 

5.5 

— 

— 

— 

— 

S.  F.  S. 

58 

80 

4.9 

5.3 

— 

— 

— 

— 

T.  R. 

70 

92 

5.2 

5.6 

39 

44 

107 

Ill 

J.  H.  C. 

80 

102 

5.8 

6.9 

41 

45 

95 

105 

*  Further  information  about  some  of  these  patients  may  be  obtained 
by  finding:  these  initials  in  Table  1,  Cannon,  W.  B.:  Acidosis  in  Cases 
of  Shock,  Hemorrhage  and  Gas  Infection. 

t  Irregular. 

once  appears.  In  other  words,  when  hemorrhage  com- 
plicates shock,  the  blood  in  the  peripheral  capillaries 
contains  relatively  more  corpuscles  in  a  given  volume 
than  that  in  the  veins,  though  in  both  the  number  is 
reduced. 

Observations  from  day  to  day  on  the  capillary  blood 
in  cases  of  shock  have  shown  that  there  is  gradually 
a  drop  to  normal  or  below  in  the  count  and  in  the 
hemoglobin  and  hematocrit  readings.  In  some 
instances  this  return  to  normal  has  occurred  on  the 
second  day ;  in  others  it  may  not  have  been  completed 
for  three  or  four  days.  A  fairly  typical  case  of  the 
slower  recovery  is  the  following: 

Case  69  a. — Private  L.  was  admitted  suffering  from  wounds 
of  the  face  and  arm,  with  fracture  of  skull ;  early  gas  infec- 
tion, severe;  moderate  shock. 


38 

The  red  count  on  admission  was  7,510,O(X);  the  ne^t  day  it 
was  still  hiyh  (7,560.000)  ;  on  tiie  third  day  it  fell  slightly  tu 
7.280,000,  and  on  the  fourth  day  it  was  5,610.000.  Counts  made 
on  five  days  during  tlic  following  week  disclosed  no  furtlier 
important  cliangc.  The  hemoglobin  and  hematocrit  readings 
likewise  fell  during  the  first  three  days,  though  not  so  sharply 
as  the  red  count.     The  record  is  presented  in  Ciiart  3. 

The  infltiencc  of  cold  in  ])roducing  .stagualion  or 
concent  ration  of  blood  in  the  capillaries  has  been  men- 
tioned. It  is  in  the  capillary  region  that  the  corpuscles 
are  most  exposed  to  contact  with  the  vascular  wall, 
that  is,  in  this  region  and  in  the  liner  arterioles  friction 


Chart   3    (Private   L.). — Cuviiit   of   icd   corpuscles,   with   heniatocril   anil 
hemoglobin  readings. 


is  greatest,  and  the  energy  stored  in  the  arterial  pres- 
sure is  mostly  used  up.  \\'hen  arterial  pressure  is  low. 
as  in  shock,  there  is  naturally  a  tendency  of  the  blood 
corpuscles  to  gather  in  the  place  of  greatest  resis- 
tance.'" And  if  these  channels  are  differentiated  by 
cold,  so  that  some  (the  warmer)  oflFer  easier  courses, 
and  others  (the  cooler)  more  difficult  courses  for  the 
blood  to  take,  the  accumulation  of  corpuscles,  especially 
in  the  capillaries  of  the  skin  and  limbs,  may  reasonably 
l)e  accounted  for  as  a  partial  stasis.  The  blood  thus 
checked  in  capillary  areas  would  be  out  of  currency, 
and  by  failure  to  return  to  the  heart  would  contribute 
to  a  lowering  of  arterial  pressure. 

10.  Cohnstcin  and  Zuntz:  Arch.  f.  d.  ges.  Physiol.,  1888,  42,  326. 


39 

TiiK    TU/)Oi)    CirANCES    PECur.rAR    to    TTemorrttage 

Many  wounded  men  have  lost  much  blood ;  they  are 
not  suffering  from  infection,  and  they  appear  to  have 
only  such  elements  of  the  shock  complex  as  the  hemor- 
rhage itself  may  induce.  The  question  arises  as  to 
whether  under  these  circumstances  examination  of  the 
blood  discloses  any  features  that  will  differentiate 
hemorrhage  from  shock. 

Blood  counts  of  hemorrhage  cases  show  several  dis- 
tinctive features.  The  capillary  red  count  is  usually 
much  lower  than  that  of  shock  alone,  but  is  by  no 
means  as  low  as  the  pallid  appearance  of  the  patient 
might  lead  one  to  suspect.  In  twenty-one  cases  classi- 
fied chiefly  as  hemorrhage,  the  average  capillary  count 
at  the  time  of  admission  or  shortly  thereafter  was 
about  5,000,000  corpuscles,  with  variations  ranging 
from  5,800,000  to  3,900,000.  In  a  few  of  these  cases 
in  which  the  venous  blood  was  also  counted",  it  proved 
considerably  lower  than  the  capillary  count.  This  is 
what  might  be  expected,  for  in  severe  hemorrhage  the 
blood  pressure  is  reduced,  and  the  cooling  of  the  body 
induces  stasis,  just  as  in  shock. 

Another  feature  of  hemorrhage  that  seems  fairly 
characteristic  is  a  relatively  low  hemoglobin  reading. 
In  the  twenty-one  cases  of  hemorrhage,  the  hemoglobin 
percentage  was  72.  If  a  count  of  5,000,000  corpuscles 
is  taken  as  normal,  the  color  index  would  be  only  0.72, 
and  even  with  6,000,000  taken  as  normal,  the  index 
is  only  0.9.  In  shock  cases,  the  index  is  approximately 
1,  with  6,000,000  corpuscles  regarded  as  the  normal 
number. 

The  primary  reduction  in  the  count  and  in  the  hemo- 
globin percentage  in  cases  of  hemorrhage  is  followed 
by  a  further  fall.  The  following  instance  is  illustra- 
tive: 

Private  G.  was  admitted  with  severe  wounds  of  the  left 
leg.  Both  tibial  vessels  were  severed,  and  there  had  been 
profuse  bleeding.  There  was  marked  pallor  of  all  cutaneous 
and  mucous  surfaces.  The  blood  examinations  on  admission 
and  on  successive  days  disclosed  a  fall,  and  later  the  begin- 
ning of  recovery.  On  admission  the  red  count  was  5.100,000, 
the  hemoglobin  68  per  cent.  For  the  next  three  daj^s  both 
figures  fell ;  on  the  third  day  the  red  count  was  3.070,000, 
the  hemoglobin  39  per  cent.  This  tendency  continued,  but 
at  a  slower  rate,  until  the  sixth  day,  when  the  count  was 


40 


1.900,000  and  the  hemoglobin  35  per  cent.  From  this  point 
a  betterment  began,  and  on  the  eighth  day  the  connt  was 
2,550.000.  the  hemoglobin  38  per  cent.  On  the  fifth  day  there 
were  present  in  tlic  blood  tilm  very  small  cells  resembling 
microcytes.  Throughont  the  examination  no  poikilocytosis 
was  observed. 

We  have  had  several  opportunities  of  coiifirniing,  on 
men  who  have  served  as  donors  in  the  transfusion  of 
blood,  the  chauij^cs  seen  in  the  foregoing  case.  In  these 
conditions  there  could  be  no  question  of  shock  or 
sepsis.  The  initial  red  count  of  the  case  illustrated  in 
Chart  4  was  5,600,000,  the  hemoglobin  102  per  cent. 
Transfusion  was  performed  by  the  direct  method,  and 
it  was  estimated  thai  about  700  c.c.  of  blood  passed 
from  the  donor.  Some  hours  later  the  capillary  count 
was  still  high,  5,700,000,  but  the  hemoglobin  reading 
had   fallen  to  88  per  cent,     Tlic  changes  during  the 


Chart   4. — Ucd   count   ritul    liciiioglobin   percentage   in   a   case   of   lienior- 
rliagc. 

next  few  days  are  shown  in  ihc  chart.  The  typical 
posthemorrhagic  fall  occurred,  but  the  hemoglobin  was 
relatixely  lower  than  the  count.  In  shock  cases  with 
hemorrhage  as  a  noteworthy  feature,  there  is  usually 
a  relatively  low  hemoglobin  content  of  the  blood. 

We  may  infer  from  the  foregoing  evidence  that  a 
low  hemoglobin  reading  is  highly  suggestive  of  a  hcm- 
orrhaire's  having  occurred. 


PosTOPER.vTivi-;    Blood    Changes 

Tracing  the  course  of  blood  changes  in  shock  cases 
has  led  to  numerous  observations  being  made  both 
before  and  after  operation.  In  all  these  cases  the 
operation  was  performed  with   warmed  ether  as  the 


41 

.•iiicsthctic.     'I1ic   results   of   the  oljsrrvalions  may  1)C 
thus  smnniarizcd : 

(a)  When  an  operation  is  associated  with  consid-^ 
crahle  hlecding,  both  hcmof^lobin  and  red  count  are 
re(hiced;  Init,  as  in  the  hemorrhage  cases,  the  hemo- 
gl()])in  falls  relatively  more  than  the  count.  This  obser- 
vation has  been  conhrmcd  in  numerous  instances. 
'J1ie  following  case  is  illustrative: 

Case  18  a. — The  patient  liad  a  severe  compound  fracture 
of  femur.  Before  admission  the  hemorrhage  had  hcen  slight; 
the  red  count  was  5,600,000,  hemoglohin  90  per  cent.  The 
necessary  operation  was  accompanied  hy  much  bleeding,  and 
the  count  then  was  4,600,000,  the  hemoglobin  50  per  cent.  The 
fall  in  the  hemoglobin  percentage  in  this  case  was  excessive; 
as  a  rule  it  amounted  to  about  10  per  cent. 

(b)  When  the  operative  hemorrhage  is  slight,  the 
count  and  hemoglobin  reading  after  operation  are  com- 
monly higher  than  before,  and  the  longer  the  operation 
the  greater  the  changes  are  likely  to  be.  Subjoined  is 
an  illustrative  case: 

Case  14  a. — A  patient  was  admitted  with  a  wound  of  the 
abdomen  through  which  a  portion  of  the  small  intestine  pro- 
truded;  the  intestine  itself  was  damaged.  Hemorrhage  had 
been  slight.  The  red  count  before  operation  was  6,400,000, 
hemoglobin  112  per  cent.  The  operation  was  completed  with 
a  minimum  of  bleeding;  about  1  foot  of  small  intestine  was 
resected.  The  operation  lasted  forty-five  minutes,  and  at  the 
end  the  red  count  was  8,000,000,  the  hemoglobin  130  per  cent. 

Perspiration  is  commonly  a  prominent  feature  of 
these  cases  during  the  course  of  the  operation — a  con- 
dition which  suggests  that  the  concentration  of  the 
blood  that  we  have  noted  is  at  least  in  part  due  to 
loss  of  fluid  from  the  body.  That  it  is  not  due  solely 
t^a  stasis  of  blood  in  peripheral  capillaries  is  shown- 
by  observation  of  venous  blood  before  and  after  opera- 
tion. In  one  instance,  in  which  there  was  profuse 
sweating  during  the  operative  procedure,  the  venous 
hematocrit  determinations  showed  a  rise  of  corpuscle 
volume  from  32  to  40  per  cent,  in  forty-two  minutes. 

A  puzzling  feature  that  may  be  mentioned  here  is 
the  change  observed  in  the  circulating  blood  when  a 
considerable  quantity  of  blood,  previously  shed,  but 
retained  in  one  of  the  body  cavities,  is  removed.  The 
removal  is  followed  by  a  marked  drop  in  the  hemo- 
globin percentage  and  in  the  red  count.    An  explana- 


42 

tioii  of  the  phenomenon  is  lackinp;;  it  has  hcen  repeat- 
edly ohscrved. 

Cask  41  a. — The  patient  had  sustained  a  penetrating  wound 
of  the  chest,  with  much  hemorrhage  into  the  left  plcur.il 
cavity.  On  tlie  day  of  admission  the  red  count  was  8.000,000, 
hemoglobin  80  per  cent.;  the  next  day  the  count  was  attain 
8.000,000.  hemoglobin  78  per  cent.  On  the  folluwing  day  2 
pints  of  fluid  blood  were  aspirated  from  tlie  clicst.  Within 
eighteen  liours  thereafter  the  red  count  had  fallen  to  5,000,000, 
and  the  hemoglobin  percentage  to  52.  Twenty-four  hours 
later  the  count  was  4,500,000,  hemoglobin   56  per  cent. 

In  some  cases  operation  seems  to  inchice  a  fraj^jmcn- 
tation  of  the  red  corpuscles. 

Blood    Changes    Observed    After    Various 
Injections 

As  means  of  treating:  hemorrhagic  and  shock,  trans- 
fusion of  hlood  and  injections  of  solutions  of  salt  and 
of  gum  have  been  widely  employed.  We  have  made 
observations  on  the  blood  before  and  after  such  treat- 
ment has  been  tried. 

A.    blood   transfusion 

From  500  to  700  c.c.  of  blood  have  been  transfused 
from  donor  to  recipient,  either  directly,  artery  to  vein, 
or  by  means  of  the  Kimpton  tube.  No  diluting  or 
chemical  substance  has  been  added  to  the  blood.  Nat- 
urallv  transfusion  is  done  when  the  blood  count  is  low, 
and.  as  is  to  be  expected,  a  great  improvement  occur.s 
in  the  recipient's  condition.  The  following  case  illus- 
trates the  degree  of  improvement  that  may  take  place: 

Case  100  a. — The  patient  had  received  severe  multiple 
wounds;  one  leg  had  been  blown  off.  The  red  count  before 
•  transfusion  was  1,900.000,  hemoglobin  31  per  cent.  It  was  esti- 
mated that  about  600  c.c.  of  blood  were  transfused  directly 
from  a  donor.  Twelve  hours  later  the  red  count  was  3,000,000, 
hemoglobin  56  per  cent.  Twenty-four  hours  later  the  count 
was  2,500,000,  hemoglobin  60  per  cent.  Thenceforth  there  was 
steady  improvement. 

B.     INJECTION     OF     GUM     SOLUTION 

A  7  per  cent,  solution  of  gum  acacia  in  physiologic 
sodium  chlorid  solution  has  been  advocated  by  Bayliss" 
to  raise  blood  pressure  in  shock  and  after  hemorrhage. 

11.  Bayliss:    Proc.    Roy.    Soc,    1916,    89,    380. 


43 

Wc  had  occasion  to  note  the  (effect  of  llic  injection  of 
this  sohition  on  the  blood  count: 

Case  64a. — The  patient  had  sustained  a  severe  abdominal 
wound,  with  profound  collapse.  A  pint  of  6  per  cent,  solu- 
tion of  gum  acacia  was  injected  intravenously.  Before  the 
injection  the  red  count  was  4,500,000,  hemoglobin  84  per  cent. 
Three  hours  after  the  injection  tlie  count  was  3,800,000,  and 
the  hemoglobin  78  per  cent. 

The  persistence  of  the  dilution  of  the  blood  in  this 
case  is  noteworthy. 

C.     IIVrERTONIC     SALINE     INJECTIONS 

The  hypertonic  solution  was  made  according  to  the 
formula :  sodium  chlorid,  2.0 ;  potassium  chlorid,  0.05  ; 
calcium  chlorid,  0.05,  and  water  100.  Injection  of  this 
fluid  produces  effects  that  are  illustrated  in  the  cases 
given. 

Case  65  a. — The  patient  had  sustained  a  compound  fracture 
of  femur;  the  limb  was  almost  severed;  there  was  consider- 
able hemorrhage.  In  the  first  blood  examination  the  capillary 
count  was  5,290,000,  hemoglobin  84  per  cent. ;  the  venous  count 
4,700,000,  hemoglobin  75  per  cent.  Immediately  after  opera- 
tion a  pint  of  hypertonic  salt  sc^lution  was  injected  intrave- 
nously. Five  hours  later  the  capillary  count  was  4,600,000, 
hemoglobin  70  per  cent. 

Case  60  a. — The  patient  had  a  compound  fracture  of  tibia 
and  fibula,  with  considerable  bleeding.  There  was  early  gas 
infection.  The  patient's  appearance  was  pallid.  Shortly  after 
admission  the  capillary  red  count  was  6.330,000,  hemoglobin 
102  per  cent. ;  the  venous  count  was  4,200,000,  hemoglobin  94 
per  cent.  After  operation  2  pints  of  hj-pertonic  salt  solution 
were  injected  intravenously.  Six  hours  later  the  capillary 
count  was  4,120,000,  hemoglobin  55  per  cent. 

It  is  noteworthy  in  these  cases  that  the  capillary 
red  counts,  some  hours  after  the  injection,  were  much 
lower  than  the  original  capillary  counts,  but  corre- 
sponded fairly  closely  with  the  original  venous  counts. 
This  change  may  be  interpreted  as  a  disappearance  of 
the  capillary  concentration,  probably  due  in  part,  at 
least,  to  improvement  in  the  circulation.  The  striking 
feature,  however,  is  the  greatly  lowered  hemoglobin 
reading  when  the  larger  amount  of  the  hypertonic 
solution  was  injected.  Why  this  change  occurs  is 
difficult  to  explain.  It  is  a  serious  disturbance  in  an 
important  element  of  the  blood,  however,  and  sug- 


44 

jjcsts  that  care  should  he  exercised  to  avoid  iiitrochicing 
unnecessarily  large  amounts  of  hypertonic  solutions. 

The  \\\lue  of  Blood  Examinations  fok 

PrcT«3N0SIS 

Only  repeated  examinations  of  the  hlood  are  of 
proii^nostic  \alue ;  conclusions  cannot  he  drawn  from  a 
single  ol)Scr\ation.  After  this  conditional  statement 
we  would  call  attention  to  the  two  following  points : 

A.     TIIK      SIGMFICANCF.      OF      CONTINUED      CONCENTRA- 
TION    OF     PERIPHERAL     BLOOD 

The  concentration  of  cai)illary  hlood,  which  occurs 
in  shock,  if  persistent,  ai)pears  to  indicate  an  unfavor- 
able prognosis,  and  an  increasing  concentration  is  a 
significant  precursor  of  a  fatal  outcome.  The  inter- 
relation between  the  clinical  condition  and  the  per- 
sistence of  capillary  concentration  is  illustrated  in  the 
following  cases : 

Case  78  a. — The  patient  was  admitted  with  a  bullet  wound 
of  the  abdomen.  Operation  disclosed  two  perforations  of  the 
ascending  colon.  On  admission  the  capillary  red  count  was 
8,300,000,  hemoglobin  96  per,  cent.  The  blood  was  examined 
on  each  of  the  following  four  days : 

July  13,  red  count  7,800,000 ;  hemoglobin  104  per  cent. 

July   14,  red  count  6,600,000;   hemoglobin  98  per  cent. 

July   15.  red  count  7,400,000;   hemoglobin  98  per  cent. 

July  16,  red   count  7,100,000;  liemoglobin  99  per  cent. 

During  this  period  the  clinical  condition  of  the  patient 
was  precarious;  there  was  restlessness,  persistent  thirst,  and 
low  blood  pressure,  with   rapid  pulse. 

On  the  fifth  day  the  capillary  blood  count  suddenly  fell  to 
5,200,000,  hemoglobin  82  per  cent. ;  and  on  the  next  day  still 
farther,  to  3,700,000,  hemoglobin  68  per  cent.  This  change 
synchronized  with  a  striking  improvement  in  the  general  clin- 
ical condition,  and  an  uninterrupted  recovery  followed. 

Case  14  a. — The  patient  was  admitted  with  a  gunshot  wound 
of  the  abdomen,  and  perforation  of  the  small  intestine.  The 
capillary  red  count  was  6,489.000,  hemoglobin  112  per  cent. 
At  the  end  of  twenty-four  hours  the  concentration  had 
increased,  and  the  count  then  was  8,700,000,  hemoglobin  130 
per  cent.  This  case  terminated  fatally  within  the  next  twenty- 
four  hours. 

Whether  the  persistent  concentration  of  the  capillary 
hlood  is  due  to  a  circulation  inadequate  to  establish 
and  maintain  a  uniform  distribution  of  corpuscles,  or 


45 

is  due  to  sonic  chcniical  alteration  in  the  corjHisdcs 
or  in  the  cajjillary  wahs,  we  do  not  wish  at  this  time 
to  consider.  The  ohservations  recorded  in  the  fore- 
going cases,  however,  we  have  had  repeated  opportu- 
nities to  verify. 

H.     THE    SIGNIFICANCE    OF     PROGRESSIVE     DILUTION     OF 
THE     BLOOD 

As  ]>reviously  pointed  out,  the  intial  concentration 
of  the  capillary  hlood  normally  passes  away  after  a 
few  days.  The  hlood  count  falls  as  if  the  peripheral 
hlood  were  being  diluted  or  the  stagnant  corpuscles 
being  swept  away.  In  association  with  loss  of  blood, 
dilution  occurs  from  increase  of  plasma,  but  this 
process  also  is  short  lived.  A  dilution  of  the  blood 
which  continues  to  progress  beyond  the  fourth  or  fifth 
day  after  injury  is  ominous,  and  the  longer  the  dilution 
continues  the  more  unfavorable  it  becomes.  In  the 
absence  of  repeated  hemorrhage,  progressive  dilution 
signifies  the  presence  of  sepsis,  and  generally  the 
involvement  of  the  blood  stream  (septicemia).  The 
following  case  is  illustrative: 

Case  4  a. — The  patient  was  admitted  with  a  severe  wound 
of  the  buttock  and  high  compound  fracture  of  the  femur. 
The  daily  blood  examinations  are  recorded  in  Table  2. 


TABLE    2.-DAILT    EXAMINATIONS    IN    PROGRESSIVE    DILUTION 
OF    BLOOD 


Day  • 

Capillary 

Red 

Count 

Hemo- 
globin, 
per  Cent. 

Day 

Capillary 

Red 

Count 

Hemo- 
globin, 
per  Cent. 

1 
2 
3 
i 

5,400,000 
4,500,000 
4,500,000 
S,90O,00O 

85 
66 
62 
61 

5 

6 
7 
8 

2,500,000 
2,300,000 
2,200,000 
2,000,000 

54 
56 
54 
50 

The  local  wounds  were  irrigated  with  flavine,  and  were 
doing  so  well  that  it  was  difficult  to  account  for  the  pro- 
gressive deterioration  of  the  blood.  On  the  eighth  day  the 
patient  left  our  care,  but  we  learned  afterward  that  the  deteri- 
oration continued,  and  eventually  the  patient  succumbed  to  a 
septicemia. 

We  have  recorded  the  foregoing  case  as  a  single 
instance  of  the  progressive  dilution  of  the  blood, 
obscure  in  origin,  and  follow^ed  by  septicemia,  but  we 
have  made  several  confirmatory  observations. 


46 

Summary 

In  cases  of  shock  as  seen  at  a  casualty  clearing  sta- 
tion in  conditions  of  warfare,  the  red  count  of  blood, 
taken  from  various  capillaries,  is  hiijher  than  that  of 
blood  taken  from  a  vein.  The  discrepancy  is  greater 
the  more  profound  the  shock,  and  not  infrequently  is 
as  much  as  2,000,000  corpuscles  per  cubic  millimeter. 
Since  the  venous  count  is  ai)proximately  normal,  the 
condition  is  due  to  a  stagnation  of  corpuscles  in  the 
capillaries.  The  observations  by  means  of  blood 
counting  have  been  confirmed  by  hematocrit  and 
hem()i:;lobin  determinations. 

'J'his  condition  once  established  in  shock  is  only 
gradually  recovered  from ;  the  recovery  sometimes 
requires  two  or  three  days. 

After  hemorrhage,  and  in  cases  of  shock  compli- 
cated with  hemorrhage,  the  hemoglobin  reading  is  rela- 
tively low  compared  with  the  red  count. 

After  operation  attended  by  hemorrhage,  the  hemo- 
globin reading  is  again  relatively  low  compared  with 
the  count.  If  the  operation  has  not  been  accompanied 
by  hemorrhage,  the  count  and  the  hemoglobin  content 
of  the  blood  may  be  higher  than  before,  probably 
owing  to  loss  of  fluid  from  the  body. 

Transfusion  of  blood  naturally  raises  both  the  count 
and  the  hemogloljin  reading.  Injection  of  a  gum  solu- 
tion leads  to  a  dilution  of  the  blood  that  may  persist 
for  some  hours.  Intravenous  administration  of  a  large 
amount  (2  pints)  of  hypertonic  salt  solution  may 
markedly  reduce  the  hemoglobin  content  of  the  blood ; 
a  smaller  amount  (1  pint)  in  our  experience  has  not 
had  this  effect.  Injection  of 'the  salt  solution  reduces 
the  capillary  stasis. 

Continued  concentration  of  the  capillary  blood  for 
several  days  after  injury  accompanies  a  continued 
unfavorable  clinical  condition.  Disappearance  of  the 
concentration  is  a  signal  of  improvement.  Continued 
<lilution  of  the  blood,  after  the  fourth  or  fifth  day,  is 
ominous. 


ACIDOSIS     IN     CASES     OF     SHOCK, 

HEMORRHAGE    AND     CAS 

INFECTION 

W.     B.     CANNON,    M.D.     (BOSTON) 

Captain,    M.   R.    C,   U.    S.    Army 
FRANCE 

Introduction 

In  the  attempt  to  obtain  more  facts  concerning  the 
conditions  that  prevail  in  cases  of  persistent  low  blood 
pressure,  it  seemed  desirable  to  examine  the  blood  for 
certain  chemical  alterations.  Among  these  were 
changes  in  the  alkali  reserve  and  in  the  sugar  content. 
A  reduction  of  the  alkali  reserve  would  be  indicated 
specifically  by  less  than  the  normal  amount  of  sodium 
bicarbonate  in  the  blood.  This  is  the  condition  of 
"acidosis"  in  the  sense  defined  by  L.  J.  Henderson^  and 
by  Van  Slyke  and  Cullen.-  The  sugar  content  might 
be  significant  as  to  the  nature  of  the  acidosis,  and 
would  also  throw  light  on  other  processes  in  the  body. 

The  circumstances  under  which  these  studies  have 
been  conducted  required  the  use  of  simple  apparatus. 
Fortunately,  the  instrument  invented  by  Van  Slyke,^ 
by  which  the  capacity  of  the  blood  plasma  to  take  up 
carbon  dioxid  can  be  determined  rapidly  and  accurately 
permits  observations  on  this  feature  of  the  blood  to 
be  made  even  where  few  laboratory  conveniences  are 
available.  The  results  given  by  this  instrument  are 
expressed  in  volumes  per  cent,  of  carbon  dioxid,  which 
the  plasma  holds  after  being  exposed  to  an  atmosphere 
containing  5.5  per  cent,  of  the  gas  (the  concentration 
existing  in  the  alveoli,  and  present  in  the  final  air  of 
an  extreme  expiration.)  Any  figures  lower  than  50 
per  cent,  in  adults  indicate  acidosis.  In  drawing  the 
blood,  a  syringe  was  used.  In  most  cases  no  difficulty 
was  found  in  thrusting  the  needle  into  an  elbow  vein 
made  prominent  by  drawing  a  rubber  tube  around  the 
upper  arm.     Care  was  exercised  not  to  exert  such 

1.  Henderson,  L.  J.:  Science,  1913,  37,  389. 

2.  Van   Slyke  and  Cullen:   Tour.  Biol.  Chem.,  1917,  30,  291. 

3.  Van  Slyke:  Jour.  Biol.  Chem.,  1917,  30,  347. 


48 

pressure  when  the  lube  was  fastened  as  to  shut  off 
the  arterial  flow.  As  the  blood  entered  the  syringe, 
the  piston  was  gently  withdrawn.  When  sufficient 
blood  had  been  taken  (about  10  c.c.),  the  tube  was 
loosened  and  the  needle  then  withdrawn.  The  blood 
was  transferred  to  a  flask  containing  a  few  crystals 
of  neutral  potassium  oxalate.  Agitation  of  the  sample 
was  avoided.  The  plasma  was  promptly  separated 
in  a  centrifuge.  All  utensils  used  were  carefully 
washed  with  water,  alcohol  and  ether.  In  making  the 
determinations  a  check  was  invariably  obtained,  and 
in  most  cases  a  further  exposure  of  the  plasma  to  the 
alveolar  air  was  made  before  the  second  reading.  All 
the  results  presented  have  the  \alues  gained  by  these 
precautions. 

The  methods  employed  in  estimating  blood  sugar 
was  the  easy  and  reliable  one  devised  by  Myers  and 
Bailey.' 

That  the  impaired  circulation  in  cases  of  shock 
would  probably  lead  to  a  condition  of  acidosis  was 
pointed  out  by  Yandell  Henderson'^  in  1910.  Later 
Crile"  and  his  co-workers  reported  results  which  indi- 
cated that  acidosis  is  present  in  various  clinical  condi- 
tions, including  shock.  Recently  Henderson  has  revised 
his  well  known  acapnia  theory  of  shock,^  and  now 
interprets  tlie  low  carbon  dioxid  content  of  the  blood 
as  probably  not  a  primary  acapnia,  but  as  a  conse- 
quence of  acidosis. 

The  present  study  includes  an  examination  of  forty- 
seven  cases  of  low  blood  pressure,  whether  due  to 
shock  alone  or  complicated  by  hemorrhage  and  gas 
bacillus  infection  (Table  1).  Observations  have  been 
made  on  the  relation  of  acidosis  to  blood  pressure, 
pulse  and  respiration;  the  sugar  content  of  the  blood; 
the  efifects  of  anesthesia  and  operation  on  existent 
acidosis  and  low  blood  pressure,  and  the  influence  of 
alkaline  treatment  in  cases  of  extreme  acidosis. 

4.  Myers  and  Bailey:  Jour.  Biol.  Cliem.,  1916,  24,  149. 

5.  Henderson,  Yandell:   Am.   Jour.   Physiol.,   1910,  27,    167,   174. 

6.  Crile:  The  Origin  and  Nature  of  Emotions,  Philadelphia,  1915, 
p.   227. 

7.  Henderson,  Yandell;  Prince,  A.  L.,  and  Haggard,  H.  W.:  Obser- 
vations on  Surgical  Shock,  The  Journal  A.  M.  A.,  Sept.  22,  1917, 
p.   965. 


49 


Till':    Kklation    oi'    Acidosis    to    Bf/km;    I^kessure^ 

I'tlLSIC      AND      Rl'.SI'IKATION 
A.      kl'LATION      'I'O      l;I,()OI)      j'klCSSUKE 

In  forty-.scvcn  (lilTcrcnt  coincident  determinations 
of  blood  pres.surc  c'uid  carbon  dioxid  capacity,  a  rouj^h 
relation  between  the  two  was  found.  Jn  general  the 
lower  the  blood  pressure  the  lower  the  alkaline  reserve, 
that  is,  the  greater  the  acidosis.  This  relation  is  illus- 
trated in  Table  2. 


TAfil-E  2.— KELATION   BETWEEN   CARBON   DIOXID   CAPACITY 
AND  BLOOD  PRESSURE 


No.  of  Cases 

Carbon  Dioxid  Capacity 

Moan  Arterial  Pressure 

6 

8 
26 

7 

20  to  29  (av.  24) 
30  to  39  (av.  35') 
40  to  49  (av.  44) 
50  to  .50  (av.  53) 

49  mm.  hg 
59  mm.  hg 
61  mm.  hg 
G9  mm.  hg 

It  is  noteworthy  that  in  forty  of  the  forty-seven 
cases  the  mean  blood  pressure  was  below  60  mm.  of 
mercury,  and  that  in  all  these  there  was  a  carbon 
dioxid  capacity  less  than  50  volumes  per  cent. — a  con- 
dition of  acidosis  was  present.  Furthermore,  as  the 
average  carbon  dioxid  capacity  was  low,  the  average 
mean  pressure  was  likewise  low.  In  the  chart  are 
presented  the  records  of  blood  pressure,  systolic  and 
diastolic,  in  thirty-five  cases  of  shock,  hemorrhage  and 
gas  infection,  arranged  in  the  order  of  decreasing 
carbon  dioxid  capacity  (increasing  acidosis).  From 
this  group  moribund  patients  treated  wdth  alkaline 
drink  have  been  eliminated.  The  first  six  of  these 
cases  had  a  carbon  dioxid  capacity  of  50  per  cent, 
or  higher,  and  are  not  to  be  regarded,  therefore, 
as  instances  of  acidosis.  The  remaining  twenty-nine 
cases  range  roughly  in  correspondence  with  the  state 
of  the  blood. 

In  ten  cases  classified  as  uncomplicated  shock,  the 
average  systolic  and  diastolic  pressures  when  the  blood 
samples  were  taken  were  77  and  52  mm.  of  mercurv, 
and  the  average  carbon  dioxid  capacity  was  41  per 
cent.  In  seven  cases  of  clear  hemorrhage,  the  relation 
again  was  77  and  52  in  blood  pressure  to  47  per  cent, 
carbon  dioxid  capacity.  And  in  thirteen  cases  with 
gas  infection  prominent,  the  average  pressures  were 


50 


70  and  43,  with  38  per  cent,  as  the  average  of  the  car- 
hon  ihtjxid  it-achngs.  These  groups  are  i)erhaps  too 
small  to  i)crnnt  conclusions  to  be  drawn.  The  ligures 
suggest,  however,  that  hemorrhage  alone  is  not 
attended  by  as  great  aVeduction  of  the  alkali  reserve 
as  is  shock  (wiien  the  blood  pressures  are  equally 
reduced),  and  again,  when  the  blood  pressure  is  low, 
as  in  the  cases  of  gas  infectiun.  the  alkali  reserve  is 
likely  to  be  correspondingly  low. 


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^  ^ 

i 

[  i 

i 

i 

-•- 

Kecords  of  blood  pressure  in  tliirty-livc  cases  of  shock,  hemorrhage 
and  gas  infection,  arranged  in  the  order  of  decreasing  carbon  dioxid 
capacity    (increasing  acidosis). 

These  6bservations  add  another  to  the  known  sim- 
ilarities between  hemorrhage  and  shock.  In  both,  the 
alkaline  reserve  is  lessened.  Milroy^  has  recently 
pointed  out  that  hemorrhage,  experimentally  induced, 
is  attended  by  reduction  of  reserve  alkali,  and  that 
thereupon  exposure  of  the  plasma  to  the  same  carbon 
dioxid  concentration  as  before  the  hemorrhage  devel- 


8.  Milroy:  Jour.  Physio!.,  1917,  51,  272. 


51 

ops  an  I T-ioii  conccnlr.'ifioii  rroisiflcralfly  lii<;licr  llinii 
before. 

In  the  cases  under  consideration  no  observa- 
tions were  made  on  the  11-ion  concentration  of  the 
blood.  l*rol)ably  the  concentration  was  not  much 
raised  when  the  alkaH  reserve  was  only  slightly  below 
normal.  The  activity  of  the  resi)iratory  center  in  some 
cases,  however,  indicated  a  markedly  increased  concen- 
tration.    These  conditions  will  be  dealt  with  later. 

From  the  evidence  presented  above,  the  conclusion 
is  warranted  that  bodily  statues  characterized  by 
reduced  blood  pressure  and  consequently  by  defective 
circulation  are  accompanied  by  a  diminished  alkali 
reserve,  and  that  as  a  general  rule  the  lower  the 
pressure  the  lower  the  reserve.  This  acidosis  should 
not  be  compared  with  that  which  may  occur  acutely 
after  a  quick  run  or  other  sharp  exercise.  That  may 
be  quite  as  extreme  as  any  change  seen  in  shock,  but 
it  is  temporary,  and  the  alkaline  stores  in  cells  and  in 
other  body  fluids  than  the  blood  may  soon  compensate 
for  the  sudden  reduction  of  available  alkali  in  the 
blood,  and  oxidative  processes  rapidly  restore  the 
normal  conditions.  In  the  cases  under  consideration, 
on  the  other  hand,  some  process  has  been  going  on 
for  hours  (often  six  or  eight)  that  has  brought  about 
the  state  observable  at  admission  of  the  patient.  The 
progressive  character  of  the  process  was  shown  in 
a  case  in  which  the  carbon  dioxid  capacity  one  hour 
after  the  wounding  was  50  per  cent.,  and  five  hours 
later,  with  no  corrective  treatment,  had  fallen  to  40 
per  cent.  The  condition  has  a  gradual  rather  than  an 
acute  onset. 

B.     RELATION     TO     PULSE 

With  low  arterial  pressure,  a  rapid  pulse  may  be 
expected.  In  the  series  of  cases  here  reported  the 
heart  was  seldom  beating  faster  than  144  per  minute. 
Possibly  that  is  a  limiting  rate  for  continued  action. 
The  average  rates  were  somewhat  below  this  number. 
Table  3  is  arranged  on  the  basis  of  increasing  diastolic 
pressures. 

Since  the  average  pulse  rates  are  fairly  uniform  for 
different  ranges  of  low  blood  pressure,  and  since,  as 
shown  above,  there  is  a  relation  between  the  lowness 
of  the  pressure  and  acidosis,  it  follo\vs  that  there  is 
no  definite  relation  to  be  found  in  our  cases  between 


52 


the  (liniinished  alkali  reserve  ami  the  rapidity  of  the 
heart  beat.  If  tlu-  pulse  is  considered  in  these  cases 
arraiijjed  on  the  basis  of  their  carbon  dioxid  caj)acity. 
the  average  rate  for  a  carbon  dioxid  capacity  of  24 
per  cent,  is  136;  of  35  per  cent..  135,  and  of  44  per 
cent..  130. 

c.    ki:l.\ti(>n    to    ki:si'iu.\tion 

The  chemical  sliniulus  increasing  respiration  is  an 
increase  in  the  11-ion  concentration  in  the  arterial 
blood.  As  L.  J.  Henderson"  has  slu)\vn.  a  large  auKjunt 
of  acid  may  be  added  to  a  bicarbonate  solution  similar 
in  concentration  to  that  of  the  blood  before  any  con- 
siderable increase  of  acidity  occurs,  so  long  as  the 
carbon  dioxid  passes  off.  The  H-ions  of  the  blood 
do  not  increase  to  an  important  degree,  therefore,  »n 


TABLE  3.-THE  RELATION  OP  ARTERIAL  PRESSURE 
TO  PULSE 


No.  of  Cases 

Average  Pressures 

Pulse 

Systolic         Diastolie 

Av.  Rate 

Range 

5 

51 

23 

133 

114-144 

9 

00 

35 

134 

108-152 

13 

72 

U 

133 

112-150 

8 

80                       55 

133 

110-144 

7 

89                       02 

128 

100-144 

spite  of  reduced  alkali,  if  pulmonary  ventilation  pre- 
vents an  accumulation  of  carbonic  acid.  Only  when 
this  process  fails,  or  acids  increase  to  such  a  degree 
as  seriously  to  encroach  on  the  neutralizing  power  of 
the  bases  of  the  blood,  does  the  increased  H-ion  con- 
tent aft'ect  in  a  marked  degree  the  respiratory  center. 
From  a  study  of  the  alkali  reserve,  by  the  Van  Slyke 
method,  in  a  large  number  of  surgical  cases  Caldwell 
and  Cleveland'"  report  no  change  of  respiration  when 
the  carbon  dioxid  capacity  was  between  43  and  50 
per  cent.,  and  also  none  between  36  and  43  per  cent, 
when  that  condition  was  stationary;  but  if  the  reserve 
was  diiuiuishiiig  and  had  reached  that  range,  hyperp- 
nea  was  almost  always  apparent. 

The  apparatus  necessary  to  record  the  volume  of 
respired  air  in  the  cases  under  consideration  was  not 

9.  Henderson,   L.   J.:   The    Fitness   of  the   Environment,   New   York, 
1913,    pp.    149-151. 

10.  Caldwell  and  Cleveland:  Surg.,  Gynec.  and  Obst.,  1917,  25,  23. 


53 


at  hand,  but  the  rate  of  hicathiiit^  was  taken.  In  some 
of  these  cases  the  respiratcjry  rate  was  probaljly 
reduced  to  a  greater  or  less  degree  by  morjihin,  which 
was  regularly  administered  to  seriously  wounrh-d  men 
in  amounts  varying  from  '/|  to  '/.  grain,  with  an 
occasional  larger  dosage.  In  Table  4,  the  chest  cases 
and  the  abdominal  cases  have  been  omitted,  for  in  them 
the  pain  due  to  respiratory  movement  may  modify 
the  breathing  in  a  way  complicating  the  influence  of 
the  blood. 

As  the  figures  show,  the  rate  increased  as  the  alkali 
reserve  fell,  but  the  change,  as  was  to  be  expected, 
became  more  marked  as  the  limit  of  the  reserve  was 
more  nearly  approached.  The  character  of  the  respira- 
tion was  not  noteworthy  except  in  the  cases  of  extreme 
acidosis,  that  is,  with  a  carbon  dioxid  capacity  in  the 


TABLE    4.— RELATION    OF    CARBON    DIOXID    CAPACITY    TO 
RESPIRATION 


Number  of 
Oases 

Carbon  Dioxid 
Capacity 

Average  Respira- 
tory Rate 

17 
7 
6 

40  to  49  (av.  44) 
30  to  39  (av.  35) 
20  to  39  (av.  24) 

24 
28 
44 

region  of  30  per  cent  or  lower.  In  some  instances  the 
breathing  was  deep  and  vigorous,  as  in  true  ''air 
hunger,"  and  at  the  rate  of  40  or  50  times  per  minute. 
These  conditions  have  been  met  especially  in  cases  of 
infection  with  the  eas  bacillus. 


The    Sugar    Content    of    the    Blood 

Lack  of  food,  or  subsistence  on  a  carboh3^drate-free 
diet,  as  is  well  known,  will  produce  a  condition  of 
acidosis  marked  by  lowered  carbon  dioxid  tension  of 
the  alveolar  air,  increased  excretion  of  ammonia  nitro- 
gen in  the  urine,  and  the  appearance  of  acetone  bodies. 
The  low  blood  pressure  of  shock  with  attendant  slight 
urinary  secretion,  and  the  generally  depressed  state  of 
the  patient,  render  accurate  studies  of  the  urine  diffi- 
cult. The  possibility  of  a  "starvation"  acidosis  being 
present,  however,  is  suggested  by  the  fact  that  not 
infrequently  men  are  brought  to  the  casualty  clearing 
station    about    noon    who    have    been    wounded    and 


54 


shocked  in  a  nij,'ht  raid,  and  who  testify  to  having 
eaten  nothinj;  since  the  previous  afternoon,  (^n  athuis- 
sion  to  the  station,  tliey  arc  often  too  ill  to  take  nour- 
ishment. In  conse(|Ucnce  they  may. be  without  food 
for  a  time  which  mi{,dit  be  expected  to  produce 
mctalxilic  disturbance.  A  jirimc  condition  for  "star- 
vation" acidosis  is  lack  of  sufficient  carbohydrate  in 
the  body  to  play  a  necessary  role  in  the  oxidation  of 
fat,  in  this  instance  body  fat  which  is  being  used  as  a 
source  of  energy.  Determinations  of  blood  sugar  will 
show,  therefore,  whether  or  not  a  deficiency  of  carbo- 
hydrate ])rc\ails.  In  Table  5  are  presented  the  results 
of  observations  in  cases  of  shock  and  hemorrhage. 

From  these  observations  it  is  clear,  in  the  first  jilace. 
thai  there  is  no  lack  of  sugar  in  the  blond  ;  indeed,  that 

TABLE    5.-SDGAR    CONTENT    OF    BLOOD    IN    CASES    OF    SUOCK 
AND    HKMORRHAOR 


Carbon 

Blood 

Oiirbon 

Blood 

iDitinls 

Dioxid 
Capacity 

Sugar 

iDitinls 

Dioxid 
Capacity 

Sugar 

F.  W. 

34 

0.11 

A.  H.  P. 

47 

0.10 

W.  B. 

36 

0.1. 'i 

W.  G. 

47 

0.18 

0.  C.  R. 

40 

0.15 
(6  hours 
after  hit) 

0.  C.  R. 

50 

0.12 

(1  hour 

after  hit) 

J.B. 

42 

0.19 

A.  S. 

52 

0.11 
(after  op'n') 

H.  H. 

42 

0.22 

A.  S. 

60 

0.12 
(before  op'n) 

the  amount  is  commonly  above  normal — 0.1  per  cent. 
Furthermore,  there  appears  to  be  no  relation  between 
variations  of  the  carbon  dioxid  capacity  of  the  blood 
and  the  percentage  of  sugar.  In  a  few  cases  urine 
was  obtained  from  shock  cases  and  tested  for  acetone 
bodies.  The  test  for  diacctic  acid  was  negative.  The 
acidosis  of  shock  cases,  according  to  this  evidence,  is 
due  to  some  other  alteration  of  the  blood  than  the 
development  of  acetone  bodies. 

The    Effect   of    Anesthesia    and    Operation    on 
Existent  Acidosis  and  Low  Blood  Pressure 

That  anesthesia  and  operation  are  accompanied  by  a 
reduction  in  the  alkali  reserve  of  the  blood  has  been 
shown  by  Crile  and   Menten,^'   Austin   and  Jonas,'" 

11.  Crile  and  Menten:  Ann.  Surg.,  1915,  62,  262. 

12.  Austin  and  Jonas:  Am.  Jour.  Med.  Sc,  1917,  153,  90. 


55 


Morriss,"'  and  Caldwell  and  Cleveland.'"  The  largest 
drop  during  operation  recorded  by  Austin  and  Jonas 
was  10  volumes  per  cent,  carbon  dioxid  capacity,  as 
determined  with  the  Van  Slyke  apparatus.  The  figures 
re[)orted  by  Caldwell  and  Cleveland,  based  on  a  study 
of  a  large  series  of  cases  in  which  they  used  the  Van 
Slyke  method,  show  a  drop  in  the  carbon  dioxid 
capacity  between  4.7  and  7.7  volumes  per  cent,  in 
operations  averaging  about  fifty  minutes  in  duration. 
In  their  series,  however,  no  acidosis  was  present 
(except  in  one  case),  and  the  drop  barely  brought  the 
capacity  to  the  boundary  line  between  normality  and 

TABLE    6.— TESTS    AFTER    OPERATION    IN    CASES    WITH 
ACIDOSIS    AND    LOW    BLOOD    PRESSURE 


Carbon  Dioxid 

Blood 

Duration 

Capacity 

Pressure 

luitiala 

of 

Operation 

Before 

After 

Before 

After 

Operation 

Operation 

Operation 

Operation 

Mins. 

% 

% 

S.  R. 

75 

58 

46 

82-58 

58-36 

B.  S. 

40 

58 

46 

88-62 

74-42 

P.  A.  T. 

60 

56 

40 

98-80 

64-48 

G.  J.  H.  H. 

45 

50 

44 

90-62 

04-46 

W.  0. 

20* 

49 

40 

76-58 

— 

J.  H.  C. 

45 

47 

40 

102-80 

50-28 

W.  A.  T. 

60* 

46 

38 

76-36 

68-28 

O.K. 

50* 

46 

27 

84-60 

58-36 

0.  P.  H. 

70 

41 

28 

76-46 

— 

Averages 

52 

50 

38 

88-62 
(7  cases) 

62-31 

*  Anesthetized  with  nitrous  oxid  and  oxygen. 

acidosis  (50  per  cent.)  It  is  well  known  in  civil  sur- 
gical practice  that  patients  with  a  low  alkali  reserve 
(as  diabetics  with  acidosis,  and  children  whose  reserve 
is  naturally  much  lower  than  that  of  adults)  stand 
operation  poorly,  and  may  pass  from  anesthesia  into 
coma  and  die.  A  highly  interesting  and  practical 
question,  therefore,  is  raised  as  to  the  influence  of 
anesthesia  and  operation  on  wounded  men  with  an 
acidosis  already  existent.  In  Table  6  are  shown  the 
results  of  blood  tests  and  blood  pressure  readings 
before  and  after  operation  in  cases  with  a  carbon 
dioxid  capacity  below  50  per  cent,  at  the  start  or  found 
below  that  level  at  the  end  of  anesthesia. 


13.  Morriss,   W.    H. :    The    Prophylaxis    of   Anesthesia    Acidosis,    The 
Journal  A.  M.  A.,  May  12,  1917,  p.  1391. 


56 

Comparison  of  the  clianges  in  the  hlood  of  these 
wounded  men  sulTerinej  from  shock  and  unstahle  cir- 
cuhition  with  those  reported  hy  Caldwell  and  Cleveland 
reveals  that  the  average  drop  in  carhon  dioxid  capacity 
is  approximately  twice  that  seen  by  them  in  ordinary 
civil  cases.  I'^urthermore,  if  the  three  cases  are  elim- 
inated which  at  the  start  had  a  carbon  dioxid  capacity 
well  over  50  per  cent.,  the  results  show  that  the  fall 
is  likely  to  be  greater  the  lower  the  original  capacity. 
The  encroachment  on  the  reserve  of  alkali  is  greater, 
therefore,  as  the  margin  of 'safety  in  the  reserve  is 
less.  In  other  words,  the  more  marked  the  existent 
acidosis  the  more  sensitive  is  the  patient  to  ojierative 
procedures,  and  the  more  likely  he  is  to  be  let  down  by 
them  into  a  region  of  danger.  In  ten  of  the  series  of 
cases  under  consideration  the  carbon  dioxid  capacity 
before  operation  was  40  per  cent,  or  less.  The  close- 
ness of  danger  in  such  cases  may  be  realized  by  the 
fact  that  blood  taken  from  the  heart  at  the  moment 
of  death  from  shock  has  a  capacity  between  20  and  24 
l)er  cent.,  and  in  two  of  the  cases  re])orted  in  Table  6 
the  capacity  fell  to  27  and  28  per  cent,  from  an  initial 
46  and  41  per  cent.,  respectively.  Such  profound 
changes  may  occur  in  about  an  hour.  The  suddenness 
of  this  remarkable  fall  in  available  alkali  is  in  itself 
important,  for  as  Caldwell  and  Cleveland  have  pointed 
out.  the  effects  are  more  damaging  when  the  fall  is 
rapid  than  when  it  is  slow  and  gradual.  With  regard 
for  the  baneful  effect  on  internal  respiration  and  on 
other  processes  of  the  body  due  to  an  impoverishment 
of  the  blood  in  alkali,  it  is  clear  that  a  rational  treat- 
ment of  shock  should  include  provision  -against  the 
dangers  of  this  sudden  depletion. 

Table  6  brings  out  another  important  fact  of  prac- 
tical importance — the  striking  fall  of  blood  pressure 
as  a  result  of  oi)eration  in  these  cases.  In  experience 
with  patients  in  whom  the  decrease  of  the  carbon 
dioxid  capacity,  as  a  result  of  operation,  did  not  extenn 
below  50  per  cent,  (that  is,  did  not  develop  an 
acidosis,  in  the  Van  Slyke  sense),  no  noteworthy 
alteration  of  arterial  pressure  occurred.  In  fact,  both 
the  systolic  and  the  diastolic  pressure  may  be  higher 
at  the  end  of  operation  than  at  the  start,  and  seldom 
is  there  a  lowering  of  the  mean  pressure.  On  the 
other  hand,  if  the  carbon  dioxid  capacity  falls  below 


57 

50  per  cent.,  or  hcinjij  1)clow  llial  level  it  sinks  still 
lower  as  a  consequence  of  opcralion,  llie  IjUkxI  pres- 
sure may  suffer  an  astonishing  decline,  in  the  seven 
complete  records  in  Tahle  6,  the  average  fall  was  88 
and  62  to  62  and  36 — the  .systolic  pres.sure  at  the  end 
of  operation  was  commcjnly  below  the  diastolic  pres- 
sure at  the  start.  This  ominous  sinking  of  the  blood 
pressure  has  been  repeatedly  seen  during  operation 
in  shock  cases  in  which  the  alkali  reserve  was  not 
determined ;  in  all  probability  the.se  cases  should  be 
classified  with  those  in  the  foregoing  list. 

Marshall"  has  testified  that  anesthesia  with  nitrous 
oxid  and  oxygen  is  specially  to  be  recommended  in 
operating  on  men  in  shock,  because  it  leaves  the 
])aticnt  in  much  better  condition  than  do  other  anes- 
thetics. Crile  and  Lower' '^  also  have  stated  that  nitrous 
oxid-oxygen  anesthesia  is  less  likely  to  increase  shock 
than  ether.  In  two  patients  in  the  present  series, 
blood  examination  before  and  after  operation  with 
nitrous-oxid-oxygen  as  the  anesthetic,  there  was  no 
change  whatever  in  the  carbon  oxid  capacity;  it 
remained  at  58  per  cent,  in  the  one,  and  at  48  per  cent, 
in  the  other  during  operations  lasting  forty  and 
twenty-three  minutes,  respectively.  That  this  anes- 
thetic does  not  preclude  a  fall  of  blood  pressure  and 
an  attendant  alkali  reduction  is  shown  by  the  three 
cases  in  Table  6  distinguished  by  asterisks — patients 
anesthetized  wdth  nitrous  oxid  and  oxygen.  The  rate 
of  change  in  the  second  of  these  three,  however,  was 
less  than  in  any  of  the  others,  and  the  blood  pressure 
was  only  slightly  reduced.  The  charted  results  pre- 
sented by  Caldwell  and  Cleveland  sho\v  not  quite  so 
great  a  decrease  of  the  carbon  dioxid  capacity  under 
**gas"  and  oxygen  as  under  ether,  but  they  conclude 
that  the  dififerences  under  different  anesthetics  are 
negligible.  The  possibility  that  the  patient  anesthetized 
with  nitrous  oxid  and  oxygen  may  sufl:er  no  apprecia- 
ble blood  change,  and  also  that  such  changes  as  have 
been  recorded  may  be  due  in  part  to  lack  of  skill  (as 
in  allowing  the  patient  to  become  cyanosed),  gives 
support  to  the  judgment  that  it  is  the  anesthetic  to 
be  employed  when  possible  in  operating  in  cases  of 
shock. 

14.  Marshall:   Proc.   Roy.   Soc.   Med.,   1917,   lO,   27. 

15.  Crile  and  Lower:   Anoci-Association,   Philadelphia,    1914,    p.    7S. 


58 

Alkai-ink  Treatment  of  Extreme  Acidosis  in 
Shock 

'riic  (lan<jc'r  zone  that  shocked  men  arc  hahlc  to  cuter 
when  they  are  o])cratc(l  on  is  apjjroachcd,  as  already 
cxphiined,  through  a  jirecipitous  fall  of  hlood  pressure 
and  a  sharp  decrease  of  the  alkali  reserve  to  a  degree 
at  which  the  Il-ion  concentration  of  the  blood  tends 
to  increase  rapidly.  The  harmful  effects  on  tissue 
respiration  and  on  other  bodily  functions  that  occur 
when  the  li-ions  are  increased  have  already  been 
emphasized.  Wright'"  had  reported  a  lessening  of  the 
alkalinity  of  the  blood  in  human  beings  and  in  lower 
animals  infected  with  the  gas  bacillus,  a  condition 
which  he  designated  as  "acidemia."  The  evidence 
presented  above  shows  that  this  condition  is  not 
peculiar  to  toxic  shock  with  gas  infection,'^  but  is 
general  for  states  of  low  blood  pressure,  whether  due 
to  wounds  or  hemorrhage,  without  notable  infection. 
The  toxemia  is  merely  an  additive  factor.  The  rational 
treatment  of  patients  with  diminished  alkali  in  the 
blood,  as  has  long  been  recognized  in  dealing  with  the 
acidosis  of  diabetes,  is  to  supply  alkali.  Wright  sug- 
gested this  therapy  also  for  treatment  of  gas  infection, 
and  reported  good  results  in  two  instances.  Its  use 
in  combating  the  extreme  acidosis  that  may  follow 
operation  on  men  in  shock  is  shown  by  the  following 
cases : 

Private  J.  F.  J.  was  admitted,  July  27,  with  multiple  shell 
wounds  of  the  leg,  knee,  right  forearm,  chest,  and  riglit  hand. 
Considerable  hemorrhage  was  probable.  Before  operation 
blood  pressure  was:  systolic  80,  diastolic  58,  pulse  134,  res- 
piration 24,  and  not  peculiar.  The  carbon  dioxid  capacity 
was  43  per  cent.  At  operation  the  left  knee  was  resected, 
about  6  inches  of  the  right  gastrocnemius  removed,  a  long 
slit  was  made  in  the  right  forearm  with  excision  of  the 
flexor  longus  digitorum,  and  the  ring  and  little  fingers  of  the 
riglit  hand,  with  their  metacarpals,  were  taken  away.  Evi- 
dence of  gas  infection  was  found. 

Shortly  after  recovery  from  the  anesthesia,  the  blood  pres- 
sure was  68  and  40,  pulse  148,  .and  respiration  34,  deep  and 

16.  Wripht:   Lancet,  London,   1917,   1,   1. 

17.  The  importance  of  a  good  circulation  for  checking  the  spread  of 
Ras  infection  has  been  remarked  by  a  number  of  writers  on  the  subject. 
Attention  has  been  directed  mainly,  however,  to  local  tensions  in  the 
tissues  and  to  thrombosis  as  the  occasions  for  a  poor  blood  supply.  That 
a  low  general  blood  pressure  may  lie  behind  the  local  iiiijiairment  should 
be  more  generally  recognized. 


59 

vigorous.  An  hour  later,  at  10:30  p.  m.,  tlic  piilsc  was  still 
as  before,  but  the  respiration  bad  risen  to  48,  and  was 
as  energetic  as  if  there  had  been  violent  struggle.  In  spite 
of  his  wounds,  the  patient  tried  to  sit  up,  crying,  "I  must 
have  air.  I  can't  breathe."  A  cannula  was  slipped  into  an 
elbow  vein,  and  35  ounces  of  warm  4  per  cent,  sodium  bicar- 
bonate were  introduced.  A  most  dramatic  change  at  once 
occurred.  The  patient's  restlessness  and  "air  hunger"  imme- 
diately disappeared,  and  in  a  few  minutes  he  fell  asleep  with 
a  pulse  of  126,  and  quiet  respirations  26  per  minute.  A  second 
respiratory  crisis  during  the  night  requirerl  another  injection 
of  the  sodium  bicarbonate  solution.  Alkaline  treatment  was 
continued  by  mouth — 1  dram  in  8  ounces  of  sweetened  water 
every  two  hours.  On  the  following  morning  the  patient  was 
found  smoking  a  cigaret.  In  the  afternoon  the  blood  pres- 
sure was  114  and  56,  pulse  132,  respiration  28.  The  second 
day  the  blood  pressure  was  128  and  58,  pulse  144,  respiration 
38,  but  gas  infection  was  found  in  the  calves  of  both  legs. 
In  the  subsequent  operation  considerable  blood  was  lost.  The 
patient  sank  rapidly  thereafter,  and  died  in  about  three  hours. 
Private  H.  (not  in  tabulation)  was  admitted,  July  27,  with 
multiple  shell  wounds.  There  was  a  big  opening  in  the  left 
loin  with  fracture  of  the  pelvis  and  infection  of  the  muscles; 
extensive  lacerations  of  the  left  tliigh,  the  left  calf,  and  the 
right  calf,  with  gas  infection;  many  superficial  wounds  of 
back  and  chest  and  left  hand.  He  was  operated  on  at  11 
p.  m.,  but  records  of  his  blood  pressure  were  not  taken.  About 
6  o'clock  the  next  morning  his  pulse  was  150,  and  he  was  suf- 
fering from  typical  "air  hunger"  with  deep  respirations 
approximately  60  a  minute.  He  was  given  intravenously  2 
pints  of  warm  4  per  cent,  sodium  bicarbonate.  He  became 
quiet  at  once,  and  fell  asleep.  Alkaline  treatment  was  con- 
tinued by  mouth.  At  12 :  30  p.  m.  the  blood  pressure  was 
72  and  56,  pulse  140,  and  respiration  32.  The  carbon  dioxid 
capacity  was  51  per  cent.  In  the  afternoon  the  blood  pres- 
sure was  104  and  68,  pulse  132,  respiration  27.  The  condition 
was  the  same  next  morning,  except  that  the  blood  pressure 
had  risen  to  114  and  72.  The  patient  then  began  to  have  an 
oscillating  fever  temperature ;  a  foot  wound  was  found 
infected,  and  the  pathologist  reported  a  coccus  in  the  blood. 
A  blood  destruction  started,  and  at  the  end  of  a  week  the 
red  count  fell  to  1,800,000,  hemoglobin  30  per  cent.  Trans- 
fusion was  done,  with  consequent  improvement.  The  patient 
was  evacuated,  but  died  of  pneumonia  in  a  hospital  at  the  base. 

"Air  hunger"  in  such  cases  is  t3'pically  a  signal  of 
impending  death.  The  results  described  in  the  fore- 
going records  demonstrate  that  the  desperate  state  of 
the  patient  sulTering  from  the  marked  acidosis  of 
traumatic  and  toxic  shock  may  be  so  changed  by 
intravenous  alkaline  therapy  that  with  astonishing  sud- 
denness he  passes  from  distress  to  comfort,  and  may 


60 

later  recover  normal  hluDtl  pressure.  These  cases 
also  indicate,  however,  that  the  intli\iilual  who  has 
passed  through  such  a  crisis  appears  to  have  little 
resistance  and  is  exposed  to  dan<^ers  of  subsequent 
infection. 

The  development  of  acidosis  in  slujck  and  its  serious 
:iij.s;ravation  hy  surgical  ])roccdures  sugp;ested  the 
desirability  of  using,  if  possible,  preventi\c  measures — 
increasing  the  chances  of  survival  for  wounded  men  by 
avoidance  of  critical  risks.  To  throw  light  on  these 
possibilities,  the  natural  history  of  the  shocked  indi- 
viilual  should  be  known.  For  the  purpose  of  securing 
this  knowledge,  Captain  Cowell  went  to  the  front 
trenches  to  study  cases  which  were  later  traced  through 
the  aid  i)ost  ami  the  dressing  station  to  the  casualty 
clearing  station.  The  results  of  this  study  are  given 
in  the  following  paper. 

SUMMARY 

Cases  of  low  blood  pressure  due  to  shock,  hemor- 
rhage, or  infection  with  the  gas  bacillus  have  a  dimin- 
ished supply  of  available  alkali  in  the  blood,  that  is,  an 
acidosis.  As  a  general  rule,  the  lower  the  pressure  the 
more  marked  the  acidosis. 

The  pulse  is  rapid  in  these  cases,  but  does  not  vary 
with  the  degree  of  acidosis. 

The  respiratory  rate  becomes  more  rapid  as  the 
acidosis  increases  until,  shortly  before  death,  a  true 
"air  hunger"  may  prevail. 

Blood  sugar  is  usually  somewhat  increased  above  the 
normal  in  cases  of  shock  and  hemorrhage.  The  acid- 
osis in  these  cases,  therefore,  is  not  due  to  lack  of  cir- 
culating carbohydrate. 

Operation  on  men  suffering  from  shock  and  acidosis 
results  in  serious  and  rapid  sinking  of  arterial  pressure 
when  it  is  already  low,  and  in  marked  and  sudden 
decrease  of  the  alkali  reserve  of  the  blood  when  that 
reserve  likewise  is  already  low.  This  change  may  not 
occur  if  nitrous  oxid-oxygen  anesthesia,  instead  of 
ether,  is  employed,  but  that  anesthetic  affords  no  guar- 
antee against  the  ominous  decline. 

Shocked  men  suffering  after  operation  from  extreme 
acidosis  with  "air  hunger"  can  be  quickly  relieved  of 
their  distress  by  intravenous  injection  of  a  solution  of 
sodium  bicarbonate,  and  their  blood  pressure  restored 
to  normal. 


TilJ<:     INITIATION     OF     WOUND     SHOCK 
.      E.    M.    COWELL 

Cnpt.-iin,    K.   A.    M.   C,   S.    R. 
FRANCE 

Introduction 

The  name  "wound  shock"  is  suggested  in  order  to 
avoid  the  confusion  which  arises,  even  among  medical 
officers,  if  the  word  "shock"  alone  is  used.  The  term 
"surgical  shock"  used  in  connection  with  the  reaction 
of  the  body  to  wound  injury  is  also  to  be  deprecated. 

Wound  shock  may  supervene  early  on.  That  is,  the 
man  suddenly  becomes  pale,  clammy  and  pulseless ; 
and  a  low  pressure  may  be  found  as  soon  as  it  is  possi- 
ble to  make  a  reading,  fifteen  to  twenty  minutes  after 
the  man  has  been  hit.  To  this  group  of  symptoms 
with  hypotension  the  name  primary  zcound  shock  is 
oiven.  When,  on  the  other  hand,  as  the  result  of  a 
long  carry  in  the  cold  or  the  onset  of  toxemia,  or  the 
presence  of  continuous  slight  hemorrhage,  or  combina- 
tions of  these  conditions,  a  man  previously  in  good 
condition  develops  similar  shock  symptoms,  a  condition 
of  secondary  zvound  shock  may  be  said  to  exist. 

In  order  to  understand  more  completely  the  later 
phases  of  fully  developed  wound  shock,  the  necessity 
for  making  clinical  studies  of  the  earliest  manifesta- 
tions of  the  condition  became  more  and  more  empha- 
sized. Opportunities  arose  and  facilitiec  were  granted 
by  the  army  medical  authorities  for  carrying  out  the 
requisite  investigations.  A  series  of  posts  were  estab- 
lished along  the  route  of  evacuation  from  the  firing 
line  to  the  casualty  clearing  station.  Suitable  cases 
were  chosen  and  examined,  blood  pressure  readings 
taken,  and  notes  made  by  medical  officers  interested  in 
the  work.  A  spring  sphygmomanometer  was  used  at 
each  post.  In  a  few  instances  the  same  observer  fol- 
lowed the  case  for  several  miles,  in  order  to  watch  the 
patient  and  check  observations. 

It  was  thus  possible  to  collect  a  small  series  of  cases 
and  establish  the  exact  time  relations  in  the  pressure 
curves  of  both  primary  and  secondary  wound  shock. 


62 

Besides  a  study  of  the  blood  pressure,  careful  clin- 
ical notes  were  kept  of  all  cases.  In  adililion,  a  few 
hematocrit  readings  were  made  n  the  line  and  samples 
of  venous  blood  taken  for  examination  in  the  labora- 
tory for  acidosis. 

A  dynamometer  was  improvised  from  the  spring: 
blood  pressure  instrument  in  order  to  form  an  idea  of 
the  general  nniscular  i)ower  and  "tone"  of  the  nervous 
system  in  these  cases  of  hypotension. 

Besides  observations  in  actual  wound  cases,  many 
jiressure  readings  of  officers  and  men  in  different  ])arts 
of  the  line  and  under  varying  conditions  were  taken 
The  facts  observed  during  a  tour  of  duty  in  the  line  in 
February,  1917,  were  confirmed  and  amplified. 

Physiology    of    the    Fighting    Soldier 

A  good  deal  of  light  is  shed  on  the  pathog;inesis  of 
wound  shock  by  a  consideration  of  the  conditions  of 
life  of  the  soldier  in  the  zone  of  fire.  In  the  case  of 
men  living  in  the  areas  behind  the  trenches,  where  they 
are  exposed  to  occasional  shell  fire,  the  conditions  of 
food,  drink,  sleep,  and  shelter  from  the  weather  are 
practically  normal.  One  finds  an  average  systolic 
pressure  of  from  110  to  120  mm.,  with  a  diastolic  of 
from  75  to  80  mm.  and  a  pulse  pressure  of  fron.  35  to 
40  mm. 

In  the  front  line  trenches,  however,  the  conditions  oi 
existence  are  for  the  most  part  unfavorable.  The 
soldier  is  subjected  to  long  spells  of  hard  physical 
labor,  often  accompanied  by  profuse  sweating.  Sleep 
is  short,  and  generally  interrupted.  The  food  supply 
is  sufficient,  but  water  is  very  often  available  only  as  a 
limited  ration.  In  the  firing  line  and  during  battle  all 
these  factors  become  accentuated. 

For  a  large  part  of  the  year,  exposure  to  wet  and 
cold  must  be  taken  into  account.  Thus  the  man,  who 
may  be  hit  at  any  time,  is  likely  to  be  in  a  state  of 
fatigue,  with  a  tendency  to  concentration  of  plasma, 
sluggish  peripheral  circulation,  and  accumulation  of 
waste  products  of  muscular  metabolism. 

The  urine  of  such  men  is  dark,  scanty,  and  loaded 
with  i)hosphates. 

Evidence  has  already  been  obtained  which  .shows 
that  in  conditions  of  this  kind  at  an  exposed  active 


63 

sector  of  the  line  the  average  systohc  pressure  was  a 
Httle  above  the  normal,  that  is,  from  120  to  130  mm. 
Pressures  were  found  without  exception  to  he  raised  at 
times  of  increased  activity,  with  the  following  average 
results:  systolic  pressure,  from  140  to  160  mm.;  dia- 
stolic pressure,  from  70  to  100  mm.;  pulse  pressure, 
from  60  to  70  mm.  Communication  of  the  details  of 
these  observations  must  at  present  be  deferred. 

It  is  not  possible  to  make  similar  observations  in  the 
heat  of  battle,  but  there  is  no  doubt  that  these  physio- 
logic conditions  are  all  present,  only  in  a  much  greater 
degree,  affording  important  prewound  factors  in  the 
initiation  of  wound  shock. 

Classification   of    Wounds    with    Reference 
TO   THE    Incidence    of   Wound    Shock. 

From  the  point  of  view  of  the  production  of  shock, 
the  wounded  may  be  divided  into  the  three  following 
classes : 

A.  Trivial  wounds,  which  cause  only  slight  damage 
to  the  tissues. 

B.  Moderately  severe  wounds,  in  which  the  ana- 
tomic disturbance  disables  the  man,  but  is  not  sufficient 
immediately  to  endanger  life. 

C.  Serious  wounds  which,  from  the  nature  of  the 
injury,  must  of  necessity  prove  mortal,  or  which  will 
cause  death  unless  the  man  is  given  surgical  attention 
within  a  short  time. 

CLASS     A.     TRIVIAL     WOUNDS 

In  these  a  transient  psychic  disturbance  may  occur, 
and  the  man  become  pale  and  sweat.  But  in  three 
cases  of  fainting  after  being  wounded,  the  pressure, 
which  was  taken  as  soon  as  possible  after  the  recovery 
from  the  faint,  was  found  to  be  normal.  In  men  who 
are  more  "highly  strung"  an  excitement  stage  may  fol- 
low a  trivial  wound.  "For  example,  a  boy  18  years  of 
age,  with  very  slight  multiple  superficial  shell  Avounds, 
exhibited  a  systolic  pressure  of  180  mm.  In  this 
group  of  cases  the  question  of  temperament  plays  a 
prominent  part.  Examination  was  made  of  a  party 
of  slightly  wounded  men,  belonging  to  a  county  infan- 
try battalion,  as  they  came  back  into  the  firing  trench 


64 

from  a  raid.  The  averajj^c  systolic  pressure  was  110 
inni. ;  only  one  man  had  a  reading  as  high  as  130  mm. ; 
he  was  talkative  and  excited. 

Apropos  of  this  question,  the  experimental  work  of 
Cannon^  and  his  co-workers  on  the  jjhysiology  of 
excitement  is  very  interesting  and  eminently  applicable 
to  the  soldier  in  battle.  According  to  this  author,  a 
defmite  series  of  psyclu)logic  events  results  from  the 
application  of  suitable  psychic  stimuli,  i  he  main  fac- 
tor is  the  outpouring  of  suprarenal  secretion,  which 
helps  to  transform  the  animal  into  a  fighting  mechan- 
ism. The  circulation  is  better  maintained  by  the  raised 
blood  pressure ;  the  heart  and  skeletal  muscles  can  do 
more  work  with  their  increased  su[)ply  of  blood  sugar, 
and  in  the  event  of  a  wound  being  received  the  coagu- 
lation time  of  the  blood  is  so  diminished  that  clotting 
occurs  more  quickly  and  the  bleeding  is  staunched. 

In  the  excitement  cases  the  pressure  subsides  rapidly 
with  quiet  and  rest.  In  the  case  of  the  boy  of  18,  it 
had  fallen  to  160  and  90  in  thirty  minutes  and  126  and 
80  in  the  next  hour. 

CLASS     B.     MODERATELY     SEVERE     W^OUNDS 

In  this  group  arc  included  those  wounds  which  cause 
a  certain  degree  of  damage  to  the  tissues,  but  either  a 
vital  organ  is  not  involved  at  all,  or,  if  such  is  involved, 
the  damage  is  slight,  as  in  a  small  jierforating  wound 
of  the  abdomen,  and  danger  to  life  docs  not  develop 
for  some  hours.  In  these  cases  primary  wound  shock 
does  not  as  a  rule  occur.  If  the  patient  is  examined 
within  a  few  minutes  where  he  fell,  he  presents  no  sign 
of  general  systemic  disturbance,  and  the  blood  j^ressure 
remains  within  normal  limits.  After  the  lapse  of  a 
short  time,  however,  and  as  a  result  of  the  operation  of 
yertain  factors  which  are  to  a  great  extent  avoidable, 
the  symptoms  of  shock  with  hypotension  appear,  and 
the  patient  then  shows  secondary  wound  shock 
(Chart  1). 

For  example,  a  man  (a)  wa.s  hit  by  a  shrapnel  ball 
which  fractured  his  femur,  lie  was  j^assing  along  the 
trench  just  outside  the  aid  post  at  the  time,  and  was 
treated  by  the  medical  officer  at  once.  His  pulse  was 
72  and  pressure   120  and  80.     Again,  by  a  curious 

1.  Cnnnon:  Bodily  Changes  in  Pain,  Hunger,  Fear  and  Rage,  New 
York,    1915. 


C5 


cliaiicc,  a  shell  liit  a  house  in  which  was  a  parly  of  men 
(/;),  four  of  wlioni  sustained  coiupouiid  fractures  (jf 
the  femur,  without  developin.^  inmiechate  shock. 
Another  case  (c)  was  observed  in  an  outpost  in  the 
front  \u\c,  when  a  bomb  arrived  which  killed  one  man 
on  the  spot  and  wounded  his  chum,  '^llie  foot  of  this 
luau  was  partially  shattered  and  his  shoulders  and  neck 
sprinkled    by    lillle    fra,<;inents.      His    blood    ])ressiu-e, 


Chart  1. — Secondary  shock  curves,  diagrammatic:  In  many  wound 
cases  the  pressure  will  remain  level  (A).  In  others,  as  a  result  of 
hemorrhage  or  exposure  to  cold,  there  is  a  drop  of  pressure  with  the 
establishment  of  a  secondary  shock  (B).  If  the  patient  is  at  this  stage 
well  cared  for  and  the  wound  not  too  severe,  the  pressure  will  rise 
during  tlie  next  stage  of  the  journey  (C)  or  remain  stationary  iD), 
improving  after  admission  to  the  casualty  clearing  station  (£).  In  the 
absence  of  favorable  circumstances,  the  pressure  goes  steadily  down  and 
the  case  terminates  fatally,  usually  in  from  twelve  to  twenty-four 
hours    (F). 


which,  as  it  happened,  had  been  found  to  be  110  and  70 
a  short  time  before,  remained  unaltered. 

One  other  example  (d)  of  this  class  of  case  may  be 
quoted,  which  possibly  is  exceptional,  but  which  is 
nevertheless  of  interest.     A  strong,  burly  lance-cor- 


66 

])()r.il,  a  boxer  of  good  rc'initation,  was  hit  by  a  shell 
which  carried  away  his  left  leg  halfway  between  the 
knee  and  the  ankle  and  also  shattered  his  right  foot. 
When  seen,  soon  after,  his  ]nilse  was  96  and  systolic 
pressnre  115  mm.  Clinically,  one  would  say  none  of 
the  usual  symptoms  of  shock  were  present.  As  the 
pain  was  consi(k'ra])le.  ho  was  at  once  given  a  hypo- 
(k'rmic  injection  of  niorpliin.  '  .••,  grain,  by  the  medical 
ollicer. 

The  immc/iiate  after  history  of  these  wounded  men 
is  instructive. 

The  man  (a),  with  a  compound  fracture  of  the 
femur,  who  was  hit  outside  the  aid  post,  was  warm  at 
the  time.  1  fc  was  put  on  a  stretcher  at  once,  well 
wrapped  u]),  and  sent  down  to  the  next  post  on  the  line 
of  exacuation.  (Jn  arrival  here  his  pulse  was  72  and 
pressure  still  normal.  Since  he  was  ([uite  comfortable 
in  liis  splint,  he  was  kept  several  hours  before  being 
Sent  to  the  casualty  clearing  station,  and  developed  no 
signs  of  shock. - 

The  four  men  {b),  hit  in  the  same  house,  were 
splinted  at  once  and  i)laced  on  a  motor  ambulance, 
which  was  dri\  en  at  a  walking  jjace  to  a  casualty  clear- 
ing station  within  half  a  mile.  No  shock  developed, 
and  all  did  well. 

In  the  example  of  the  man  (c)  hit  by  a  l)omb  at  the 
outpost,  secondary  wound  shock  (le\eloi)ed.  lie 
arrived  cold  and  jnilseless  at  the  lid  post.  Before  he 
was  hit  he  was  cold,  fatigued  and  thirsty  ;  and  during 
the  carry  of  an  hour  and  a  half,  exposed  to  the  chill 
wind  preceding  dawn,  he  lost  more  heat.  Fear,  too, 
was  probably  superimposed  as  a  factor  in  this  case, 
since  on  the  journey  down  the  stretcher  party  was 
exposed  to  occasional  shells  and  biu'sts  of  machine  gun 
fire.  A  sound  man  feels  moderately  secure  in  the 
trenches  because  he  can  take  cover;  but  a  man  who  is 
already  hit  and  is  being  carried  along  on  a  stretcher, 
shoulder  high,  feels  helpless.     At  the  next  stage  this 

2.  There  is  little  doubt  th.it  since  the  universal  introduction  of  liie 
Tlioin.is  splint  for  fr.nctures  of  the  femur,  wliicli  lias  provc<i  increascil 
comfort  to  the  patient  and  immohilization  of  the  fraKmcnls  of  the  bone, 
the  incidence  of  secondary  shock  has  been  greatly  diminished.  Such 
patients  used  to  arrive  at  the  casualty  clearing  station  with  well  estab- 
lished shock  showing  systolic  pressures  of  80  or  90  mm.  or  less. 
Similar  cases  now  arrive  with  systolic  and  diastolic  pressures  of  130 
and  90,   120  and  80,  or  even  160  and   100  in  one  case. 


67 

man  was  still  pulseless.  Very  soon  after  being  admit- 
ted to  the  casualty  clearing  stalion.  lK)wever,  he  was 
warmed;  his  pulse  returned,  and  lie  did  well  without 
the  exhibition  of  any  antishock  nictliods  of  treatment. 

The  boxer  (d),  with  his  leg  blown  off,  also  devel- 
oped secondary  wound  shock,  lie  did  not  manifest 
any  lowering  of  tension  on  the  journey  from  the 
trenches  to  the  advanced  dressing  station,  but  on 
arrival  at  the  casualty  clearing  station,  about  five  hours 
after  his  being  wounded,  toxemia  was  beginning  to 
develop,  and  the  pressure  harl  dro])pcd  from  114  and 
70  to  88  and  62  mm. 

Before  leaving  the  second  group  of  cases,  another 
example  of  marked  wound  shock,  but  with  quick 
recovery,  may  be  mentioned.  A  young  soldier  (c)  in 
a  wiring  party  sustained  two  simple  bullet  wounds  of 
the  fleshy  part  of  the  thigh.  It  v/as  a  cold  night.  After 
being  carried  two  hours,  with  no  hemorrhage,  he  was 
found  to  be  cold,  thirsty  and  pale,  with  a  pressure  of 
70  and  50  mm.,  and  a  small  thready  pulse  of  68.  He 
was  given  a  hot  drink  and,  after  being  warmed  and 
well  wrapped  up,  was  sent  off.  At  the  next  post  his 
arterial  pressure  had  risen  to  120  and  80  mm.,  and 
remained  at  that  level  on  arrival  at  the  casualty  clear- 
ing station. 

CLASS     C.     SERIOUS     WOUNDS 

In  the  third  group  a  serious  surgical  condition  has 
resulted  from  the  wounding.  The  wound  shock  comes 
on  early,  and  apparently  in  proportion  to  the  gravity 
of  the  lesion^  (Chart  2). 

In  primary  wound  shock,  very  definite  clinical  symp- 
toms may  be  observed.  For  example,  the  driver  of 
an  ambulance  car  was  hit  in  the  abdomen  by  a  shell 
fragment  as  he  arrived  at  the  dressing  station  on  a 
warm,  sunny  morning.  He  fell  down,  and  within  a 
few  minutes,  as  his  wound  was  being  dressed,  drew 
the  attention  of  the  medical  officer  to  his  profuse 
sweating.  He  was  wrapped  up  in  blankets,  hot  bottles 
were  applied,  and  he  was  sent  oft'.  After  thirty  min- 
utes' ride  over  a  rough  road,  scarred  by  shell  holes,  he 
was  found  to  be  responsive  to  questions.  He  com- 
plained of  pain,  and  presented  cold,  clammy  extremi- 
ties, with  the  sweating  still  marked.   He  was  pale,  with 

3.  The  only  predetermining  factor  of  any  importance  in  the  amount 
of  shock  which  may  result  is  the  temperamental  stability  of  the  patient. 
This   point   is  illustrated   in   some   of  the   following   cases. 


68 

a  pulse  of  96  and  a  pressure  of  100  ami  70.  On 
arrival  at  the  casualty  cloarinti;  station,  about  forty-five 
minutes  later,  the  pressure  had  further  dropped  to  82 
and  70  and  the  pulse  had  risen  to  100.  Operation  was 
l)erfonned  in  time  to  stop  further  hemorrha<,a'.  Ten 
rents  in  the  bowel  were  repaired,  and  after  intraxenous 
infusion  he  e\entuallv  made  a  jrood  recoverv. 


d.. 

0               1               :                 1                4 

no 

90 
CO 
70 
60 
:j 
40 
.       30 



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J 

\ 

^Q 



P 

/ 

/ 

\ 
\ 
\ 

^ 

1         } 

/ 
/ 

\ 
\ 

V 

1      / 
1    / 

o 

s 
-■-o— 

LCcnJai 

f 

P, 

o 

,nor,y 

Chart  2. — Priin.iry  wound  sliock  curves;  iliiiKr-iiiinialic:  riillowing  the 
receipt  of  a  severe  anatomic  injury,  where  deatli  must  ensue  or  where 
life  can  be  saved  only  by  prompt  surgical  interference,  instant  shock 
appears  accompanied  by  hypotension.  Tliis  may  be  fatal  in  a  short  lime. 
If  all  precautions  arc  taken  in  the  careful  transit  of  the  patient,  the 
pressure  may  rise  cii  route  or  remain  level  without  furtlier  drop.  After 
the  lapse  of  a  few  hours  the  condition  of  primary  wound  shock  merges 
into   that  of  secondary   wound   shock   unless   recovery   has   first   occurred. 

A  few  Other  examples  of  severe  injuries  with  early 
wound  shock  may  be  quoted,  in  which  circulatory  dis- 
turbance predominated.  In  these  cases,  whenever  the 
systolic  pressure  was  found  below  from  60  to  70  mm.. 
it  was  always  a  distressing  symptom. 

Case  1. — A  man  on  a  working  party  was  seen  about  forty 
minutes  after  being  hit  by  a  sliell  burst.  He  liad  sustained 
penetrating    wounds   of   the   cliest,   buttocks,   legs   and    thigh, 


69 

with  fracture  of  the  femur.  He  was  cold,  with  a  clammy 
skin ;  pulse  80,  and  l)lood  i)rcssure  60  and  50  mm.  He  com- 
plained loudly  of  thirst  and  pain.  His  sensation  was  nor- 
mal, and  as  the  antitoxin  needle  was  inserted  he  cried  out. 
Respiration  was  from  20  to  24,  with  no  unusual  character- 
istics. Morphin,  Vi  grain,  hypodermically,  stoi)pcd  the  pain 
in  a  few  minutes;  and  after  a  few  hours'  warming  he  was 
sent  on  with  a  pulse  of  90  and  pressure  of  98  and  70. 

Case  2. — A  young  officer,  of  a  nervous,  irritable  disposition, 
was  hit  in  the  dorsal  region  of  the  spine  by  a  sniper  just 
after  dawn.  Two  hours  later  his  blood  pressure  was  75  and 
SO,  pulse  84,  and  all  the  signs  of  wound  shock  were  present. 

Case  3. — A  large,  powerfully  built  gunner  was  seen  within 
half  an  hour  after  being  hit.  one  hot,  sunny  morning.  The 
shell  fragments  had  fractured  his  lower  jaw  and  left  femur. 
He  was  cold,  sweating,  pulseless  and  thirsty.  The  systolic 
pressure  was  about  30  mm.  There  was  considerable  hemor- 
rhage. He  was  treated  in  tlie  routine  way  and  sent  down. 
He  improved  for  a  time  at  the  casualty  clearing  station,  but 
eventually  died  of  gas  gangrene. 

Case  4. — Another  man,  hit  by  a  slicll  wliile  on  a  working 
party  on  a  cold,  wet,  muddy  night,  was  brought  to  the  advanced 
dressing  station  within  fifty  minutes.  He  was  found  to  have 
multiple  severe  wounds,  including  compound  fractures  of 
botli  a  femur  and  a  humerus,  with  laceration  of  the  muscles. 
When  examined,  the  wounds  looked  like  dead  tissues.  There 
was  no  bleeding,  and  practically  no  capillary  oozing.  His 
systolic  pressure  was  40  mm.  Mentally  he  was  quite  bright 
and  responsive,  so  that  the  medical  officer  in  charge  of  the 
case  remarked  on  the  patient's  "wonderful  fitness."  The  man, 
however,  was  dead  within  the  hour. 

Case  5. — Another  man  had  a  severe  wound  of  the  buttock, 
penetrating  the  abdomen.  He  was  seen  a  short  time  before 
death,  about  two  hours  after  he  was  hit.  He  was  pulseless 
at  the  wrist,  with  a  blood  pressure  of  about  30  mm.,  and  was 
so  restless  that  he  had  to  be  held  on  the  stretcher  by  two 
orderlies. 

Case  6. — A  thin,  lightly  built  sergeant  of  anxious,  worrying 
disposition  was  hit  as  he  lay  asleep  at  the  foot  of  his  dug- 
out, by  a  shell  which  shattered  both  his  feet.  His  company 
commander,  a  medical  man,  was  fetched  within  two  minutes 
and  found  him  unconscious  and  pulseless.  Both  feet  were 
pulped,  but  not  bleeding.     He  died   about  an  hour  later. 

The  "grip,"  as  recorded  by  the  improvised  dynamo- 
meter in  those  cases  of  profound  hypotension  in  which 
it  was  possible  to  make  this  test  of  muscular  power, 
was  in  all  cases  practically  the  same  as  for  a  normal 
man. 


70 

Conclusions 

1.  The  psychology  and  physiology  of  the  average 
healthy  "veteran"  soldier,  living  in  the  fightin,,  zone 
under  "peace"  conditions  are,  for  practical  purposes, 
normal. 

2.  In  hattle  and  at  points  of  actixity,  the  conditions 
of  excitement,  cold,  thirst,  fatigue  and  possihly  loss  of 
sleep  hccome  inijiortant  pre.  ound  factors  in  the  initia- 
tion of  wound  shock. 

3.  Wounds  may  he  classified  into  three  groujjs  with 
regard  to  the  incidence  of  shock. 

Triznal  woutids,  such  as  slight  scalp  injuries  or  small 
lesions  of  suhcutaneous  tissues  only,  give  ri.se  to  neither 
primary  nor  secondary  wound  shock.  Transient 
psychic  distur])ances  of  cither  depression  or  excitement 
may  result,  accom]janied  by  a  normal  or  raised  blood 
pressure. 

In  moderately  severe  wounds,  such  as  uncomplicated 
compound  fracture  of  the  femur,  a  slight  penetrating 
wound  of  the  abdomen  or  a  lacerating  wound  of 
muscle  without  urgent  hemorrhage,  as  a  rule,  primary 
wound  shock  is  absent,  that  is,  if  the  patient  is  seen 
within  a  few  minutes.  If  circumstances  permit  of  suf- 
ficient care  being  taken,  probably  no  untoward  symp- 
toms will  arise,  and  secondary  wound  shock  may  be 
averted  (Cases  a  and  h). 

As  the  factors  of  cold,  toxemia,  pain,  anxiety  or  lack 
of  water  are  allowed  to  come  into  play,  however,  there 
develojis,  after  a  lapse  of  several  hours,  secondary 
wound  shock  (Cases  c,  d,  and  c). 

Into  the  category  of  serious  xvouuds  will  fall  a  large 
group  of  cases  in  which  the  wound  must  of  necessity 
prove  mortal.  Symptoms  result  immediately  and 
hypotension  is  found  from  the  carlfcst  moments  (Cases 
1  to  6).  This  is  primary  wound  shock.  Such  shock 
is  likely  to  be  produced  to  a  greater  degree  in  men 
possessing  temperamental  instability.  After  a  few 
hours,  unless  recovery  has  first  occurred,  the  condition 
of  primary  wound  shock  merges  into  that  of  secondary 
wound  shock,  owing  to  the  operation  of  the  same  con- 
ditions, cold,  pain,  anxiety.  In  the  slighter  cases, 
recovery  from  primary  symptoms  is  rapid  (Case  1)  ; 
but  then  exposure  and  the  factors  enumerated  in  B 
may  come  into  play,  and  secondary  wound  shock 
become  established. 


A     a;NSlJJl-:kATI(JN     ()\'     Till'.     NATURI': 
OF     WOUND     SHOCK 

W.     J'..     CANNON,     M.\).     (BOSTON) 

C.ipt;iin,   M.   K.   C,  U.   S.   Army 
FRANCE 

Introduction 
The  previous  pa])er.s  of  this  series  have  consisted 
mainly  of  records  of  ohserved  phenomena  in  cases  of 
shock,  with  Httle  discnssioli  of  their  origin  or  signifi- 
cance. These  ohservations,  however,  have  suggestive 
values  and  are  pertinent  to  theoretical  aspects  of  the 
sljiock  problem.  A  consideration  of  the  bearings  of 
our  results  on  previous  views  of  the  nature  of  shock 
may  bring  out  some  new  points  and  may  be  useful  in 
directing  further  investigation  into  fruitful  channels. 

T]iE    Bearing    of    Present    Work    on    Previous 
Theories    of    Shock 

A.    the   acapnia    theory 

The  thesis  advanced  by  Yandell  Henderson  that 
shock  is  due  to  a  reduction  of  the  carbon  dioxid  of  the 
blood  (acapnia)  has  received  much  attention.  In  sup- 
port of  his  view,  Henderson'^  produced  low  blood 
pressure  in  animals  by  vigorous  artificial  respiration, 
and  he  assumed  that  the  lowered  carbon  dioxid  content 
of  the  blood  thus  induced  was  the  prime  factor  in 
establishing  the  shocklike  state.  In  all  probability, 
however,  the  effect  was  due,  not  to  reduction  of  carbon 
dioxid,  but  to  mechanical  obstruction  to  return  of  blood 
to  the  heart  and  to  consequent  failure  of  the  circula- 
tion. Only  by  such  extreme  inflation  of  the  lungs  as 
would  hinder  the  passage  of  venous  blood  through  the 
veins  of  the  chest  were  Janeway  and  Ewing-  able  to 
obtain  the  results  described  by  Henderson,  and  they 
succeeded  equally  well  when  the  normal  carbon  dioxid 
content  of  the  blood  was  maintained. 

Further  doubt  is  thrown  on  Henderson's  views  by 
observations  on  the  character  of  the  breathing  in 
wounded  men  suffering  pain.  Deep  and  vigorous  ven- 
tilation of  the  lungs  is  required  to  produce  a  marked 

1.  Henderson,  Yandell:  Am.  Jour.  Physiol.,  a  series  of  papers,  190S- 
1910. 

2.  Janeway  and  Ewing:  Ann.   Surg.,   1914,   59,   158. 


/I 

(liniiinition  of  the  carbon  dioxid  content  of  the  blood. 
Lowell  made  a  special  point  of  lookiiij^  for  that  type  of 
respiration  in  recently  wounded  men,  but  did  not  see  it. 
And  in  a  man  brouijht  under  my  observation  at  the 
clearing  station  a  few  moments  after  he  had  been  hit 
in  the  wrist  by  a  bomb  splinter,  which  was  jj;ivin,<j  him 
much  i)ain,  cxj)losivc  respirations,  preceded  by  holding:; 
the  breath,  were  goins;  on  at  the  rate  of  12  per  minute. 
I'Vom  the  evidence  in  hand  it  appears  that  painful 
wounds  are  not  directly  associated  with  a  hyperpnea 
that  would  produce  acapnia^. 

Recently  Henderson,  Prince  and  Haggard'  have 
reported  hnding  in  animals  exi)crimcntally  shocked  a 
condition  of  acidosis;  and  since  the  blood  in  this  state 
has  a  reduced  capacity  for  carbon  dioxid,  he  has  given 
the  "acapnia"  theory  a  new  interpretation — the  carbon 
dioxid  is  low  because  of  the  acidosis.  The  observations 
previously  reported'  confirm  in  human  cases  the  evi- 
dence secure(l  experimentally.  Shock  is  accompanied 
by  acidosis,  and  the  ability  of  the  blood  to  take  uj) 
carbon  dioxid  is  corresjiondingly  reduced. 

Henderson  has  raised  the  question,  however,  as  to 
whether  the  alkali  of  the  blood  controls  the  carbon 
dioxid  content,  or  the  carbon  dioxid  content  controls 
the  alkali.  Apparently  reluctant  to  abandon  his  acapnia 
theory,  he  suggests  that  in  shock,  excessive  breathing 
may  greatly  lower  the  carbon  dioxid  of  the  blood,  and 
that  as  a  protective  com])ensation  acidosis  is  developed 
to  prevent  the  fatal  apnea  that  might  ensue  from  lack 
of  stimulating  H-ions.  Again  it  is  projier  to  emi)hasize 
the  observation  that  such  hyperpnea  as  would  result 
in  marked  reduction  of  the  circulating  carbon  dioxid 
is  absent  from  wounded  men.  To  be  sure,  the  cblorin 
content  of  the  plasma  increases'^  as  carbon  dioxid 
leaves  the  blood,  but  as  any  one  may  easily  demonstrate 
to  himself,  this  is  not  a  jiroccss  of  sufikient  magnitude 
to  prevent  ajjuea  after  vigorous  hyperpnea.  Further- 
more, in  shock,  acidosis,  in  the  sense  of  a  lessened 
alkali  reserve,  occurs  before  any  noteworthy  efifect  on 
respiration  is  manifest.     These  considerations  render 

3.  Henderson,  Yandell;  Prince,  A.  L.,  and  Haggard,  H.  W.:  Obscr 
vations  on  Surgical  Shock,  The  Journal'  A.  M.  A.,  Sept.  22,  1917, 
p.   965. 

4.  Cannon,  W.  B.:  Acidosis  in  Cases  of  Shock,  Hemorrhage  and  Gas 
Infection,   p.   47. 

5.  Hamburger:  Osmostischer  Druck  und  lonenlehre,  Wiesbaden, 
1902.,  I,  p.  264.  See  also  Austin  and  Jonas:  Am.  Jour.  Med.  Sc,  1917, 
cliii,    p.    86. 


7Z 

highly  qticsti()iial)lc   I  Icndcrson's  suggestion  of  a  jjri- 
mary  acapnia. 

Henderson''  and  also  rorlci"  have  advocated 
rehrcathing  cxi)ired  air  as  a  means  of  imj)roving  the 
circulation  in  shock.  1  icndcrson's  ohjcct  is  to  main- 
tain the  carhon  dioxid  content  of  tlic  hlorxl  in  sjjile  of 
an  alkali  deficit,  with  the  idea  that  alkali  may  ihus  he 
mohilized  and  the  circulatory  apparatus  henefitcd. 
Porter's  ohjcct  is  to  increase  the  amplitude  of  the 
movements  of  the  diaphragm  so  that  the  sufferer  who 
has  hied  "into  his  own  ahdominal  veins"  may  pump  the 
hlood  from  this  reservoir  into  the  heart.  The  certain 
effect  of  the  increase  of  the  carhon  dioxid  in  the  hlood 
is  to  increase  the  Il-ion  concentration.  That  this  stim- 
ulates not  only  the  respiratory  center  hut  also  the  vaso- 
motor center  was  shown  by  Mathison.'^  The  ability  of 
the  vasomotor  center  to  respond  to  stimulation,  even  in 
profound  shock,  was  proved  by  Porter''  in  190<S.  That 
the  increased  arterial  pressure  ol)tainable  by  increasing 
the  H-ions  of  the  blood  would  be  only  temporary  was 
to  be  expected.  As  one  of  Porter's  cases  shows,  the 
raised  pressure  promptly  fell  to  the  former  shock  level 
as  soon  as  the  carbon  dioxid  administration  stopped. 
The  respiratory  mechanism,  of  course,  at  once  gets  rid 
of  the  excess  of  carbon  dioxid,  the  H-ion  concentration 
falls,  and  the  stimulus  which  raised  the  pressure  is 
thereby  reduced.  There  are  possibilities  of  harm  in 
this  procedure,  however,  that  should  not  be  overlooked. 
As  Milroy"  has  recently  demonstrated,  when  the  alkali 
reserve  is  reduced,  exposure  of  the  plasma  to  a  given 
concentration  of  carbon  dioxid  increases  the  H-ion 
content  to  a  much  greater  degree  than  is  the  case  when 
the  plasma  is  normal.  Increase  of  the  H-ion  concen- 
tration interferes  with  cellular  oxidation.  If  the 
patient  rebreathes-  his  expired  air,  the  oxidative  proc- 
esses are  further  interfered  with  through  diminished 
oxygen  supply.  Thus,  nonvolatile  acids  may  arise 
which  fix  the  alkali  and  lead  to  a  more  permanent 
increase  of  the  H-ion  concentration  of  the  blood.  The 
state  of  acidosis  which  already  exists  in  the  shocked 
man  may,  therefore,  be  distinctly  aggravated  by  the 
procedures  advocated  by  Henderson  and  by  Porter. 

6.  Porter:  Boston  Med.  and  Surg.  Jour.,  1917,  176,  699;  177,  326 

7.  Mathison:   Jour.   Phvsiol.,   1910,   41.   430. 

8.  Porter:  Am.   Tour.  Phvsiol.,  1908.  20,  404. 

9.  Milroy:   Jour.   Physiol.,   1917,   51.  279. 


74 

In  this  connection  the  testimony  of  Marshall,  who  as 
an  expert  anesthetist  in  a  casualty  clearing  station  has 
had  lar<:;e  experience,  is  jiertinent.  lie  has  declared 
that  the  most  imjiortant  consideration  in  anesthetizing 
]iatients  sutTering  from  hemorrhage  or  shock  is  to 
avoid  anything  in  the  nature  of  asphyxia;  indeed,  that 
if  such  a  patient  hecomes  cyanoscd,  he  loses- ground 
that  can  hardly  he  recovered.  This  warning  is  in 
accord  with  the  contention  that  any  action  increasing 
acidosis  is  to  he  avoided. 

1'..    THE     ll)i:.\    OF    SUI'R.NKENAI.    KX 1 1  .MSTION 

Since  remoxal  of  the  suprarenal  glands  results  in 
lowered  arterial  pressure,  and  since  secretion  or  injec- 
tion of  the  extract  of  the  suprarenal  medulla  increases 
the  pressure,  the  idea  has  been  advanced  that  in  shock 
there  is  suprarenal  exhaustion  and  conse(|Ucnt  hypo- 
tension.'" If  the  distinction  which  should  he  drawn 
between  the  effects  on  blood  pressure  of  the  medullary 
and  cortical  portions  of  these  glands  is  for  the  moment 
disregarded,  it  may  be  pointed  out  that,  according  to 
Short,^'  who  used  a  very  delicate  test,  the  epinei)hrin 
content  of  the  glands  in  fatal  cases  of  shock  is  not 
notably  reduced.  Furthermore,  Mann'-  has  reported 
that  total  excision  of  the  suprarcnals  does  not  repro- 
duce the  phenomena  of  shock. 

There  is  experimental  testimony  tliat  i).'iiiiful  sliniuli 
and  asphyxia  increase  both  the  secretion  of  cpinei)hrin 
and  the  percentage  of  sugar  in  the  blood,  and  that  the 
sugar  i)ercentage  does  not  rise  if  the  suprarenal  glands 
are  not  cooperati\'e.^''*  Persons  suffering  from  wound 
shock  have  been  se\erely  stimulated,  and  the  low  blood 
pressure  which  characterizes  their  condition  produces 
a  state  which  is  equivalent  to  partial  asphyxia.  Bed- 
ford and  Jackson^'  and  later  Bedford  rej^orted  finding 
the  ei)inephrin  content  of  the  blood  increased  if  the 
blood  pressure  is  low.  The  high  ])erccntage  of  sugar 
found  in  our  series  of  shock  cases  likewise  indicates 

10.  Corbctt.    J.    F. :    The    Suprarenal    Gland    in    Shock,    The   Journal 
A.    M.  A.,  July   31.    1915,  p.   380. 

11.  Short:    Lancet,   London,   1914,    1,    131. 

12.  Mann,  F.  C. :  Shock  During  General  Anesthesia,  The  Journal 
A.    M.   A.,   Aug.   4,    1917.   p.   371. 

13.  Cannon.  W.  B.:  Bodily  Changes  in  Pain,  Hunger,  Fear  and 
Rage,   New   York,   1915,   pp.   69-77. 

14.  Bedford  and  Jackson:  Proc.  Soc.  Exper.  Biol,  and  Med.,  1916. 
X3,  85-87.     Bedford:  Am.  Jour.  Physiol.,  1917,  43,  235. 


75 

that  the  suprarenal  glands  arc,  if  .-mylliing,  overactive 
•rather  than  exhausted. 

C.     THE     NEKVE     EXHAUSTION     THEORY 

When  observers  noted  that  arterial  tension  is  low  in 
shock,  the  first  suggestion  offered  was  that  relaxation 
of  the  arterioles  had  occurred,  and  in  consequence 
there  was  no  support  for  the  head  of  pressure  which 
the  heart  might  oliierwise  develop.  This  view,  long 
ago  expressed  l)y  Mitchell,  Keen  and  Morehouse,  has 
been  elaborated  by  Crile'''''  in  extensive  investigations 
on  the  blood  pressure  and  on  the  nerve  cells  in  shocked 
animals.  It  is  his  belief  that  the  most  vital  efifect  of 
shock  is  "the  impairment  of  the  vasomotor  mechan- 
ism." The  concept  has  been  gradually  develo])ed  that 
shock  consists  essentially  of  exhaustion  of  cells  in  the 
brain,  the  liver,  and  the  suprarenal  glands.  Evidence 
that  the  suprarenals  are  not  exhausted  has  been  pre- 
sented above.  The  theory  of  a  primary  exhaustion  of 
nerve  cells  requires  examination.  It  may  be  consid- 
ered, first  with  regard  to  the  vasomotor  center,  and 
then  with  regard  to  cerebral  and  motor  functionings. 

A  lowering  of  arterial  pressure  is  not  proof  that  the 
vasomotor  center  is  inactive  or  exhausted,  for  arterial 
pressure  may  be  low  in  consequence  of  hemorrhage, 
that  is,  when  only  a  small  volume  of  blood  is  delivered 
to  the  heart  for  each  contraction.  Furthermore,  even 
when  an  animal  is  in  extreme  shock.  Porter^"  and  his 
collaborators  found  that  both  pressor  and  depressor 
reflexes  still  occur.  The  occurrence  of  depressor 
effects  proves  that  some  tonic  activity  of  the  vasomotor 
'center  is  still  present,  for  otherwise  its  action  could  not 
be  depressed ;  and  the  pressor  responses  show  that  the 
center  is  still  capable  of  increased  action  when  stimu- 
lated. These  observations  by  Porter  have  been  con- 
firmed by  Seelig  and  Lyon^'  and  by  Mann.^^ 

Since  the  vasomotor  center  is  not  exhausted,  the 
question  arises  as  to  its  actual  condition  in  shock. 
Recent  experimental  evidence  points  to  its  effective 
control   of   peripheral   and   visceral   arterioles   in   the 

15.  Crile:    Volumes    on    Surgical    Shock;    Blood    Pressure    in    Surgery; 
Anoci- Association. 

16.  Porter:   Am.   Jour.  Physiol.,   1907,   20,   399. 

17.  Seelig  and  Lyon:   Surg.,   Gynec.  and  Obst.,   1910,   11,   146. 
IS.  Mann:   Bull.  Johns  Hopkins  Hosp.,  1914,  p.  208. 


7(i 

shocked  state.  Seelij::  and  Lvdii''''  found  that  cutting 
the  nerve  of  a  leg  in  a  shocked  animal  caused  an- 
nicreased  flow  of  blood  from  the  femoral  vein,  (luth- 
rie  in  contirming  this  work,  observed  that  whereas  the 
increase  of  flow  in  a  normal  animal  was  22  per  cent., 
in  a  shocked  animal  it  was  76  per  cent.  Later,  Seelig 
and  Joseph-"  noted  that  if  in  a  shocked  rabbit  the  blood 
picssure  was  suddenly  raised  by  clami)ing  the  aorta, 
the  blood  greatly  distended  the  arteries  of  one  ear 
whose  nerves  had  jjreviously  been  cut,  but  failed  to 
distend  the  arteries  of  the  other  ear  whose  nerves  were 
still  connected  with  the  vasomotor  center.  In  other 
words,  the  center  was  still  holding  the  vessels  in  efl'ec- 
tive  contraction.  Similar  observations  have  been  made 
by  ]\Iann'-*  on  internal  organs.  And  a  number  of  inves- 
tigators have  reported  that  in  an  animal  with  low  blood 
pressure  the  rate  of  perfusion  flow  is  less  with  a  given 
pressure  than  in  a  normal  animal,  and  that  severance  of 
the  nerves  to  the  organ  or  increase  of  the  blood  flow  to 
the  vasomotor  center  increases  the  rate.-'- 

Moreover,  the  studies  of  Pike,  (aithrie  and  .'^tew- 
art""'  have  revealed  the  fact  that  the  vasomotor  center 
is  more  capable  of  withstanding  the  adverse  influences 
of  anemia  than  any  other  of  the  vital  bulbar  centers — 
the  respiratory,  the  cardio-inhibitory  or  the  swallowing 
mechanisms.  Its  capacity  to  function  is  the  last  to 
disappear  in  total  anemia,  and  the  first  to  reappear 
v.'hen  the  blood  flow  is  restored.  Obviously,  the  vaso- 
motor center  should  be  regarded  as  an  agent  whose 
functions  are  extremely  stable  and  whose  capabilities 
for  continued  service  are  its  most  outstanding  feature. 
Only  endangering  circumstances,  such  as  lessened 
blood  supply,  are  required  in  order  to  make  it  become, 
for  a  time  at  least,  more  than  usually  active. 

In  this  connection  it  is  interesting  to  observe  that  not 
infrequently  in  cases  of  profound  shock,  when  a  pulse 
cannot  be  felt  at  the  wrist,  it  can  be  felt  easily  if  the 
palpating  fingers  are  moved  up  the  arm  where  the 
arteries  are  larger,  or  applied  over  the  carotid.     Fraser 

19.  Seelig,  M.  G.,  and  Lyon,  E.  P.:  The  Condition  of  the  Peripheral 
Blood  Vessels  in  Shock,  The  Journal  A.  M.  A.,  Jan.  2,  1909,  p.  45. 

20.  Seelig  and  Toseph:  Proc.  Soc.  Expcr.  Biol,  and  Med.,  1914,  12,  49. 

21.  Mann:    Bull.    Johns    Hopkins   Hosp..    1914,    p.    209. 

22.  Morrison  and  Hooker:  Am.  Jour.  Physiol.,  1915,  37,  93.  Pilcher 
and  Sollmann:  Ibid.,  1914,  35,  59,  70.  Bayliss:  Proc.  Roy.  Soc,  Lon- 
don,   1916,    89,    391. 

23.  Pike,  Guthrie  and   Stewart:  Jour.  Exper.   Med.,  1908,   10,  499. 


77 

has  repeatedly  nolcd  while  o])eraliii^  on  slujcked  men 
such  strong-  contraction  of  <mtlyinj(  arteries  lh;i1  no 
bleeding  occurred  when  the  vessels  were  cut. 

The  evidence  from  functional  disturbance  that  j^arts 
of  the  nervous  system  other  than  the  centers  control- 
ling the  circulation  are  exhausted,  in  any  strict  sense 
of  that  term,  is  meager.  Even  when  the  blood  pres- 
sure has  been  much  reduced,  the  intelligence  remains 
clear,  the  i)atient  may  be  restless  rather  than  somnolent, 
and  often  exhibits  surprising  muscular  power.  Cowell 
re])orts  no  reduction  of  the  strength  of  grip  in  shock; 
and  he  observed  a  wounded  man,  pulseless,  with  a 
systolic  pressure  about  30  mm.,  who  was  so  vigorous  in 
his  movements  that  two  orderlies  were  required  to  hold 
him  on  the  stretcher. 

The  evidence  for  exhaustion  which  has  been 
advanced  by  Crile-'*  and  his  co-workers  is  mainly  his- 
tologic, and  is  based  on  examination  of  nerve  cells 
taken  from  shocked  animals.  It  is  improbable  that 
these  changes  are  due  directly  to  afferent  impulses,  for 
Forbes  and  Miller,""  by  use  of  the  string  galvanometer 
as  an  indicator,  found  that  anesthesia  blocks  the  pass- 
age of  impulses  to  the  brain.  The  suggestion  is  rea- 
sonable that  any  cell  alterations  that  may  occur  in 
shock  are  the  resultant  of  the  low  blood  pressure 
rather  than  its  cause.  Indeed,  Dolley  has  admitted 
that  hemorrhage  produces  the  same  alterations  in  the 
cells  that  are  seen  in  shock.  Crile's  testimony  that,  if 
the  blood  pressure  is  kept  up  by  transfusion  into  the 
shocked  animal  much  more  severe  trauma  is  required 
to  alter  the  cells  than  when  shock  takes  its  natural 
course,  is  further  testimony  to  the  same  interpretation. 
It  should  not  be  forgotten,  however,  that  histologic 
evidence  regarding  the  state  of  nerve  cells  is  subject  to 
grave  mischances  both  in  technic  and  in  interpretation. 
And  other  observers  who  have  examined  nerve  cells 
from  shocked  animals  declare  that  the  changes  are 
within  the  limits  of  normal  variations.-*^ 

Differences  in  the  appearance  of  nerve  cells  from 
separate  parts  of  the  nervous  system  might  be  regarded 

24.  Crile:  Anoci-Association,  Philadelphia,  1913,  passim.  Dollev: 
Jour.    Med.    Research,    1909,   p.    95;    1910,    p.    331. 

25.  Forbes  and  Miller:  Am.  Jour.  Physiol.,   1916,  40.   503-513. 

26.  Allen:  Proc.  Soc.  Exper.  Biol,  and  Med.,  1915,  12,  76.  Kocher, 
R.  A.:  The  Effect  of  Activity  on  the  Histologic  Structure  of  Nerve 
Cells,  The  Journal  A.  M.  A.,  July  22,  1916,  p.  27S. 


7S 

as  iiulicatiiii^  a  (Icfiiiikly  directed  agent,  such  as  nerve 
impulses,  rather  than  a  ijeneral  agent,  sudi  as  low  blood 
pressure,  at  work  to  induce  ehruiges.  The  dilYerences 
are  exi)licable,  however,  on  the  ground  that  nerve  cells 
are  differentially  sensitive  to  anemia,  and  by  exposure 
to  an  inadequate  circulation  they  would  be  differen- 
tially affected.'-' 

The  interpretation  of  cell  changes  as  the  result  rather 
than  the  cause  of  shock  points  to  a  clear  distinction 
which  should  be  drawn  between  early  and  late  indica- 
tions of  asthenia  in  shocked  men.  Though  the  vaso- 
motor centers  may  for  a  time  be  normally  active  or 
even  hyperactive,  and  the  neuromuscular  mechanisms 
may  be  ready  for  service,  continuance  of  low  blood 
pressure  and  the  develo])ment  of  an  acidosis  which 
interferes  with  internal  res])iration  will  surely  have 
deleterious  influences,  and  ultimately  will  destroy  the 
hardiest  and  most  resistant  structures.  It  is  when 
these  adverse  conditions  have  brought  to  the  point  of 
exhaustion  organs  which  are  of  \ital  importance  that 
death  occurs. 

The    Cardiac    Factor 

'J"he  foregoing  discussion  of  the  exhaustion  theory 
has  emphasized  the  evidence  that  the  low  pressure  of 
a  shocked  man  is  not  due  to  relaxation  of  the  arteries 
through  paralysis  or  inactivity  of  the  vasomotor  center. 
The  other  important  factor  in  maintaining  the  arterial 
head  of  pressure  is  the  heart.  y\s  has  been  often 
observed,  the  heart  characteristically  beats  rapidly  in 
shock  and  after  hemorrhage.*  The  suggestion  has 
been  offered  that  the  rapid  beat  is  due  to  paralysis  of 
the  cardio-inhibitory  center,  but  Mann'-'*  found  that  in 
the  shocked  animal  the  center  is  responsive  to  reflex 
stimulation  and  also  to  increase  of  intracranial  tension. 
The  neiNdus  check  on  the  heart,  therefore,  is  not 
impaired,  indeed,  the  rapid  cardiac  beat  with  hyi)0- 
tor.sion  is  precisely  what  is  to  be  expected  according  to 
the  reciprocal  relation  which  commonly  ])revails 
between  heart  rate  and  arterial  pressure. 

That  the  heart  muscle. is  not  defective  in  shock  has 
been  shown  experimentally,  liaising  the  arterial 
pressure  to  a  high  level  by  epinejjhrin  does  not  over- 

27.  For  discussion  see  Cannon  and  Burket:  Am.  Jour.   Physiol.,  1913, 
32,   347. 

28.  Mann:    Bull.    Johns   Hopkins   Hosp.,    1914,   p.   210. 


79 

whelm  tlic  licarl;  wlicti  properly  sn|)pllcil  witli  liloix!, 
it  meets  the  situaticjii  and  contracts  vvitli  v\^(>r.  J.ow 
j'.rterial  ])ressure,  liowever,  if  prolonged,  may  incapaci- 
tate the  heart,  for  Markwald  and  Starlinj^-"  have  found 
that  when  the  systolic  pressure  falls  below  (SO  mm.  of 
mercury,  the  cardiac  contraction  begins  to  weaken. 
And  Patterson'"'  has  shown  that  when  the  H-ion  con- 
centration of  the  blood  increases  (by  increased  car-, 
bonic  acid),  the  heart  relaxes  more  and  more  anrl  beats 
less  energetically.  The  low  blood  pressure  and  the 
acidosis  of  shock,  therefore,  may  in  time  imjjair  tlie 
efficiency  of  the  organ,  though  no  primary  defect  be 
present. 

The    Problem    of    the    ''Lost   Blood''    in 
Shock 

If  the  vasomotor  center  is  efficiently  at  work,  and  if 
the  heart  is  capable  of  assuming  any  reasonable  burden 
placed  on  it,  .why  is  there  a  low  arterial  pressure  m 
shock?  The  answer  to  this  question  lies  in  the  dimin- 
ished volume  of  blood  which  is  in  active  circulation. 
Henderson,  especially,  has  laid  stress  on  the  necessity 
of  a  sufficient  supply  of  blood  being  delivered  to  the 
heart,  if  arterial  pressure  is  to  be  kept  at  its  normal 
level.  In  the  absence  of  this  supply,  as,  for  example, 
after  hemorrhage,  the  arterial  pressure  falls  to  a  low 
level  and  can  be  raised  only  by  introducing  blood  or 
other  viscous  fluid  into  the  vessels. 

A  further  question  now  arises,  one  of  the  critical 
questions  in  the  mystery  of  shock,  "Where  is  the  lost 
blood  in  the  shocked  individual?"  There  are  no  indi- 
cations that  it  is  in  the  heart  or  lungs ;  it  must  be,  there- 
fore, in  systemic  arteries  or  capillaries  or  veins. 

IN    THE    ARTERIES? 

The  absence  of,  the  lost  blood  from  the  arteries  is 
sufficiently  proved  by  the  facts  already  discussed,  ^^'ith 
an  efficient  vasomotor  center  and  a  capable  heart,  an 
f.dequate  amount  of  blood  in  the  arteries  would  be 
accompanied  by  high  arterial  pressure.  That  the 
pressure  is  low,  as  already  stated,  signifies  that  the 
heart  is  not  supplied  with  enough  Mood  to  fill  the 
arterial  system. 

29.  Markwald   and    Starling:    Jour.    Physiol.,    1913,    47,    275. 

30.  Patterson:  Proc.  Roy.  Soc,  London,  1915,  B,  SS,  394. 


80 


IN    Till-:    \i:iNS 


The  \ic-\v  (.■(iniiiKiiily  lu'Kl  in  llic  past  has  l)ccii  that  in 
shock,  blood  is  staj^nant  in  the  lar<;c  venous  reservoirs 
of  the  chest  and  ah(K)nien,  and  especially  in  the  capa- 
cious splanchnic  area.  "In  shock,"  it  is  said,  "the  suf- 
ferer bleeds  into  his  own  abdominal  veins."  It  appears 
that  this  view  is  based  largely  on  evidence  from  cxj)eri- 
ments  which  has  been  rather  uncritically  accei)ted. 
The  most  certain  way  to  produce  shock  in  a  lower  ani- 
mal is  by  ex])osure  and  manipulation  of  the  intestine. 
Under  these  circumstances  the  mesenteric  veins  stand 
out  prominently,  ])lood  _i,'athers  in  the  intestinal  walls, 
and  becomes  more  concentrated  there,  and  the  struc- 
tures that  have  been  freely  handled  appear  as  if 
inflamed.^'  In  other  words,  blood  obviously  stagnates 
in  abdominal  vessels.  Such  a  condition  is  not  seen  in 
natural  shock.  According  to  Keith,''-  the  venous  cis- 
tern, formed  by  the  big  veins  of  the  chest  and  abdomen, 
has  a  capacity  of  400  or  550  c.c.  Mann''-'  has  found 
that  the  amount  of  blood  that  can  be  obtained  by  bleed- 
ing and  by  em])tying  the  heart  of  normal  animals  is  7G 
per  cent.,  leaving  24  per  cent,  "in  the  tissues."  When 
animals  are  shocked  by  exposure  of  the  intestine  the 
amount  left  in  the  tissue  rises  to  39  j)er  cent.,  a  differ- 
ence of  15  per  cent.  If  the  l)lood  mass  of  a  man  of 
70  kg.  is  taken  as  3,500  c.c,  the  amount  thus  "lost" 
would  be  525  c.c.  If  this  blood  were  in  the  veins  of 
the  abdomen,  systemic  or  splanchnic,  their  capacity 
would  have  to  be  greatly  enlarged,  and  their  distention 
would  be  clearly  visible. 

Surgeons  of  extensive  experience  at  casualty  clear- 
ing stations  in  the  i)resent  war,  who  have  ])erformed 
many  hundreds  of  abdominal  ojierations  on  ])aticnts  in 
all  degrees  of  wound  shock,  have  testilied  that  on  ojjen- 
ing  the  abdomen  they  have  not  found  any  i)rimary 
splanchnic  congestion.^'  The  method  employed  to 
produce  shock  in  lower  animals,  which  has  repeatedly 
called  attention  to  the  abdomen  and  its  peculiar  circu- 
lation, has  given  rise  to  misleading  inferences  as  to 
what  occurs  in  natural  shock  brought  on  l)y  wounding 
other  regions  than  the  abdomen. 

31.  Morrison  and  Hooker:  Am.  Jour.  Physiol.,  1915,  27,  93.  Mann: 
Surg.,   Cyncc.   and   Obst.,   1915,   65,   380. 

32.  Keith:   Jniir.  Anat.  and   Physiol. ,   1908,  62,   1. 

33.  Mann:  .Surg.,  Cynec.  and  Ohst.,  191S,  55,  380. 

34.  Statement  by  Wallace,  Frascr  and  Drummond:  Lancet,  London, 
1917,  2,   727. 


81 

If  the  lost  l)lood  were  in  the  systemic  veins,  further- 
more, it  shcHild  be  possible  jjromjitly  to  remedy  the 
condition  of  a  shocked  individual  liy  placing  his  body 
in  a  slanting  head-down  position,  bandaging  the  limbs, 
and  compressing  the  abdomen.  Such  measures  have 
been  thoroughly  tried  in  treating  shock,  and  though 
perhaps  in  some  cases  heli)ful,  they  do  not  give  results 
which  indicate  that  the  blood  which  is  out  of  circula- 
tion is  stagnant  in  the  large  venous  channels. 

The  fact  should  be  remembered  that  veins  are  to  a 
considerable  extent  subject  to  vasoconstrictor  impulses; 
and  if  conditions  are  such  as  to  continue  the  activity  or 
to  induce  an  overactivity  of  the  vasoconstrictor  center, 
the  veins  as  well  as  the  arteries  might  be  contracted. 
Venbmotor  nerves  have  not  been  demonstrated  for  all 
parts  of  the  body,  however,  and  if  there  are  veins  free 
from  nervous  control,  other  influences  causing  relaxa- 
tion might  prevail.  Only  slight  dilation,  perhaps  too 
little  to  be  conspicuous,  would  be  needed  to  increase 
considerably  the  venous  capacity.  But  there  are  no 
observations  that  the  veins  are  even  slightly  dilated  in 
shock. 

IN     THE     CAPILLARIES? 

If  in  wound  shock  the  lost  blood  is  not  in  the  arteries 
and  probably  not  to  a  great  amount  in  the  veins,  it  must 
be  mainly  stagnant  in  the  capillaries.  Observations 
reported  in  a  previous  paper^^  have  shown  that  in  shock 
a  striking  discrepancy  exists  between  the  corpuscular 
content  of  the  capillaries  and  the  veins.  There  is  a 
concentration  of  the  blood  and  a  stagnation  of  the  cor- 
puscles in  the  capillaries  which  can  be  demonstrated  in 
such  widely  separated  parts  as  the  ears,  the  fingers  and 
the  toes.  The  discrepancy  is,  to  be  sure,  more  marked 
in  superficial  areas  than  in  deeper  regions ;  but  even  in 
the  latter  a  noteworthy  difference  is  found. 

The  question  immediately  occurs.  Is  the  capillary 
capacity  sufficient  to  contain  the  lost  blood  in  shock? 
Unfortunately,  the  data  for  estimating  the  capillary 
capacity  are  not  definitely  established,  and  it  is  impossi- 
ble to  state  with  any  assurance  what  amount  of  blood 
these  vessels  may  contain.  Ranke  inferred  from  deter- 
minations made  on  freshly  killed  rabbits  that  approxi- 

_  35.  Cannon,  W.  B.;  Eraser,  John,  and  Hooper,  A.  N.:  Some  Altera- 
tions in  Distribution  and  Character  of  Blood  in  Shock  and  Hemorrhage, 
p.   32. 


82 

match'  oiu-  fiiurlli  nl"  tin.'  lilood  is  in  the  luart,  lungs 
and  m'cal  hlootl  vessels,  one  fuurlh  in  ihe  liver,  one 
fourth  in  the  restiujjj  luuseles,  and  one  fourth  in  the 
icmaininj;  orjj^ans.""  'ihe  larj^e  projiorlion  of  the  hlood. 
about  75  per  cent.,  which  is  outside  the  heart,  lungs  and 
large  veins  and  arteries,  seems  to  indicate  an  abundant 
capacity  in  the  small  vessels  lying  within  the  tissues. 
On  the  other  hand,  an  estimation  of  the  capacity  of  the 
cajMllaries,  based  on  the  inverse  ratio  Ijetween  the  rate 
of  flow  and  the  cross-section,  yields  a  rather  small  vol- 
ume for  capillary  contents.  The  most  favorable  ratio 
of  the  rate  of  flow  in  the  aorta  and  in  the  capillaries, 
stated  by  Tigerstedt,""  is  2,000:1.  The  cross-section 
of  the  aorta  of  an  adult  man  is  about  4.4  sq.cni. ;  that 
cf  the  total  cajMllary  bed,  on  this  basis,  would  be  (4.4X 
2,000)  S,800  sq.cm.  The  average  length  of  a  cajMllary 
is  given  as  0.05  cm.  The  total  capacity  of  the  capillary 
system,  therefore,  would  be  only  about  440  c.c.  This 
calculation  docs  not  take  into  consideration,  however, 
the  fact  that  capillaries  are  not  all  full  of  blood. 
J  kubncr^''  observed  after  injecting  sodium  gold  chlorid 
the  sudden  appearance  of  new  capillaries  in  the  frog's 
web,  so  that  a  coarse  mesh  was  quickly  changed  to  a 
fine  one.  And  Worm-Muller""  was  convinced  that  the 
only  way  to  account  for  the  ability  of  the  circulatory 
system  to  accommodate  itself  to  injection  of  large 
amounts  of  blood  was  to  assume  a  utilization  of  capil- 
laries not  ordinarily  filled.  He  cited  the  dift'erence  of 
a])pearance  of  the  intestine  when  at  rest  and  when 
digesting,  the  phenomenon  of  blushing  and  the  redness 
of  the  inflamed  skin  as  illustrating  the  idea  that  the 
capillary  net  may  contain  much  more  blood  than  it  usu- 
ally contains.  The  distcnsibility  of  the  cai)illaries  also 
should  be  considered,  for  Roy  and  Brown^"  noted  that 
chloroform  could  double  the  diameter  of  capillaries 
(thus  quadrupling  their  capacity).  Still  another  con- 
sideration which  is  pertinent  to  the  conditions  in  shock 
is  the  concentration  of  the  ca])illary  blood,  as  shown  in 
a  previous  paper,""'  which  means  a  retention  mainly  of 

36.  Vierordt:    Anatomische,    Physiologische    unci    Physikalische    Daten 
und   Tabellen,  Jen.i,    1893. 

37.  Tigerstedt:   Physiologic  des  Kreislaufcs,  Leipzig,   1893,  p.   423. 

38.  Ileubner:   Arch.   f.  Exper.   Path.   u.   Pharniakol.,   1907,   56,   375. 

39.  Worm-Miillcr:  Ber.  u.  d.  Vcrhandl.  a.  k.  Sachs.  Gcs.  d.  Wissensch., 
1873,  25,   650. 

40.  Roy  and  Brown:  Jour.  Physiol.,  1879,  »,  375. 


83 

corpuscles  in  tlic  ca])illarics.  All  (licsc  facts  appear  to 
warrant  the  conclusi(Mi  that  the  ca])illary  rapacity  is 
.sufficient  to  contain  the  lost  blood  in  shock,  atul  tliat  the 
chances  of  its  doinj^  so  arc  }:(reater  (he  mfjrc  concen- 
trated the  lost  blood  becomes. 

The  observations  ])reviously  reportcMl''"'  indicated  tliat 
the  capillary  blood  may  be  concentrated  to  such  an 
extent  that  a  cubic  millimeter  contains  <S  million  instead 
of  5  or  6  million  corpuscles.  An  equal  concentration 
does  not  occur  in  all  parts  of  the  body.  The  observa- 
tions of  Cohnstcin  and  Zuntz/"^  however,  suj^gest  that 
when  blood  pressure  is  lowered  (by  cutting  the  spinal 
cord)  a  capillary  stagnation  occurs  to  such  an  extent  as 
to  pack  the  vessels  closely,  while  the  venous  blood 
quickly  falls  in  corpuscular  content  (a  drop  of  about  a 
million  corpuscles  per  cubic  millimeter  in  ten  minutes). 
Lowering  of  blood  pressure  by  spinal  section  will  in 
itself,  on  this  evidence,  induce  a  stasis  which  can  be 
clearly  seen  under  the  microscope,  and  is  observable  in 
both  surface  and  internal  capillaries. ■*- 

The    Viscosity    Factor 

There  are  other  conditions  besides  a  low  blood  pres- 
sure that  are  favorable  to  capillary  stagnation  of  the 
corpuscles.  These  are  concerned  with  alterations  in 
viscosity.  The  viscosity  of  the  blood  is  complex,  con- 
sisting, as  it  does,  of  the  internal  friction  of  the  plasma, 
the  friction  of  the  corpuscles  with  the  plasma  and  \vith 
each  other,  and  the  frictional  contacts  of  the  corpuscles 
with  the  vessel  walls,  especially  in  the  capillaries. 

A  prime  factor  affecting  the  viscosity  of  blood  is  the 
number  of  corpuscles  per  unit  velume.  The  polycy- 
themia of  cholera,  for  example,  ma)'-  cause  the  viscosity 
of  the  blood  to  rise  from  4.8  to  over  20.*^  Cohnheim^* 
attributed  the  low  blood  pressure  in  cholera  to  a  failure 
of  the  blood  to  return  to  the  heart,  owing  to  the  enor- 
mous increase  of  frictional  resistance  that  is  caused  by 
concentration.  The  concentration  of  the  corpuscles  in 
the   capillaries   would,    in   itself,    render   the    friction 

41.  Cohnstein  and   Zuntz:   Arch.   f.   d.   ges.   Physiol.,   1888,   42,   326. 

42.  These  observers  did  not  consider  possible  dilution  of  the  blood  by 
tissue  fluids,  and  they  transferred  the  observations  on  capillary  stagnation 
in  the  frog  to  explain  the  conditions  they  found  in  the  rabbit.  The 
importance  of  the  results,  in  relation  to  the  nature  of  shock,  warrants  a 
careful   repetition  of  the   experiments   under  more  critical  couditions. 

43.  Bence:  Ztschr.  f.  klin.  Med.,   1906,  5S,  203. 

44.  Cohnheim:    Lectures  in   Pathology,   London,   18S9,   1,   466. 


84 

greater,  and  increase  the  resistance  to  an  onward 
movement. 

Another  agent  afTecling  the  blood's  viscosity  to  a 
notable  degree  is  temperature.  The  increase  of  inter- 
nal friction  is  related  directly  to  a  fall  of  temperature. 
Denning  and  Watson'''  found  that  viscosity  of  blood 
was  increased  3  per  cent,  with  a  fall  of  1  degree  Centi- 
grade, and  that  the  temperature  factor  was  more  effect- 
ive the  larger  the  number  of  corpuscles  present.  Even 
in  normal  persons,  application  of  cold  increases  the  red 
count  in  the  cooled  capillary  areas.  Cowell's  observa- 
tions on  recently  wounded  men  have  shown  that  a 
prompt  and  striking  reaction  to  the  injury  is  profuse 
sweating."*"  One  of  the  most  effective  modes  of  lower- 
ing body  temperature  is  through  evaporation  of  sweat ; 
indeed,  it  is  the  only  way  of  losing  heat  when  the  sur- 
rounding temperature  is  equal  to  or  exceeds  that  of  the 
body.  Normally,  as  the  surrounding  temperature  falls, 
sweating  ceases  and  heat  is  lost  by  radiation  and  con- 
duction. In  the  shocked  man  exposed  to  cold  all  three 
processes  are  going  on ;  and  the  clothing,  wet  with 
sweat  or  rain,  permits  the  loss  by  conduction  to  be 
much  augmented.  Thus  the  surface  is  liable  to  be 
speedily  cooled,  and  soon  the  whole  body  is  affected, 
it  is  common  for  the  body  temperature  (buccal)  to  be 
below  95  P.,  and  readings  as  low  as  87  and  88  have 
been  noted  in  shocked  men.  Of  course,  the  skin  and 
extremities  are  much  colder.^"  According  to  Cowell's 
observations  shivering  is  rarely  seen  under  these  con- 
ditions. The  heat  loss,  therefore,  is  not  compensated 
for  by  heat  production. 

The  increase  of  viscosity  due  to  cold  is  not  to  be 
regarded  as  the  only  factor  leading  to  cajMllary  stag- 
nation; it  is  probably  not  sufficient  by  itself  to  have 
that  effect.  Possibly  cold  affects  capillary  walls  in  a 
way  leading  to  greater  friction.  Hough  and  Ballan- 
tyne*^  have  reported  a  rise  of  capillary  pressure  in 
cooled  parts  of  the  body,  together  with  lessened  con- 
spicuousness  of  the  veins,  and  they  suggest  that  con- 
traction of  muscles  in  the  venules  may  check  the 
outflow   from  cooled  capillary  areas.     However  loss 

45.  Denning  and  W.itson:    Proc.   Roy.   Soc,   1906,   78,   318. 

46.  Cowcll,   E.    M.:   The   Initiation   of   Wound    .Shock,   p.    61. 

47.  Weil:   Miinchen.   med.    Wchnschr.,    Sept.    11,    1917. 

48.  Hough  and  Hallantyne:  Jour.  Boston  Soc.  Med.  Sc,  1899,  3,  330. 


85 

of  heal  may  oih'IviIc,  iIic  cvi'lciicc  is  clear  llial  it 
results  in  coiiceiilralion  of  blood  in  capillary  areas; 
and  this  factor,  adried  lo  the  clfcci  of  low  hlofjd 
pressure,  would  favor  si'f^rej^'ation  of  the  eorjjuscles 
in  the  capillaries.  Sis.;nirjcant  in  this  connection  is  the 
commonly  observed  j^reater  incidence  of  shock  in  cold 
weather,  and  especially  when  the  cold  is  accompanied 
by  rain,  so  that  clothing  is  wet  through.  Likewise 
stVrnificant  is  the  fact  that  as  a  wounded  man  becomes 
chilled  his  blood  pressure  falls,  and  as  he  is  warmed 
his  blood  pressure  may  rise  again.'" 

In  addition  to  concentration  of  corpuscles  and 
lowered  temperature  as  conditions  increasing  the 
viscosity  of  the  blood,  there  is  the  itifluence  of  an 
increase  of  H-ions.  I  have  already*  dealt  with  the 
existence  of  acidosis  in  cases  of  shock.  Since  there 
is  evidence  that  acidosis  has  other  efifects  than  merely 
on  the  corpuscles,  its  influence  will  be  considered  in 
some  detail. 

The    Effects    of    Acidosis    on    the    Circulation 

In  all  probability,  the  lowering  of  the  alkali  reserve 
in  cases  of  shock  and  hemorrhage  is  due  to  a  fixed 
union  of  the  alkali  with  acids,  which,  unlike  carbonic 
acid,  do  not  pass  off  in  the  lungs.  The  production  of 
such  acids  is  known  to  occur  when  oxidation  is  inter- 
fered with.  A  low  blood  pressure  with  slow  circula- 
tion, cold,  and  corpuscular  stagnation  would  all 
cooperate  to  check  the  normal  oxidative  processes 
of  the  body,  and  to  increase  the  production  of  inter- 
mediary acid  metabolites.  Emphasis  should  be  kept 
on  the  fact  that  these  metabolites  would  be  more  con- 
centrated in  the  tissues,  and  in  the  perivascular  fluids 
than  they  would  be  in  the  blood,  for  they  must  diffuse 
from  their  source  in  the  cells  into  the  circulating 
stream.  Thus,  though  the  alkali  reser\x  in  the  blood 
may  not  be  reduced  to  a  degree  which  would  indicate 
a  considerable  increase  in  the  H-ion  concentration, 
the  H-ion  concentration  in  stagnant  capillary  regions 
must  be  still  higher.  And  if  the  reserve  in  the  blood 
is  greatly  reduced  and  the  H-ion  concentration  is 
much  raised,  still  greater  concentration  must  exist 
in  the  tissues.  In  addition,  if  the  tissue  fluids  are 
cooled,  they  will  be  still  more  acid ;  for,  as  L.  J.  Hen- 


86 

derson^"  has  pointed  out,  the  alkalinity  of  the  body 
fluids  decreases  as  the  temperature  falls.  The  acids 
thus  developed  in  the  tissues  and  affecting  first  the 
capillaries  and  small  veins,  with  their  corpuscular 
contents,  mig^ht  have  effects  on  the  circulation  which 
would  augment  the  action  of  low  pressure,  concentra- 
tion and  cold  as  considered  above. 

1.  There  is  evidence  that  acid  or  change  in  the 
blood  in  the  direction  of  acidity  may  have  depressive 
cfl'ccls  on  the  blood  pressure.  Thus  Hooker^"  observed 
that  carbonic  acid  in  minimal  effective  amounts  always 
causes  relaxation  of  vascular  muscle.  And  ( iaskell,'"'' 
and  also  Bayliss,^-'  proved  that  other  acid,  for  example, 
lactic,  which  results  from  inadequate  oxidation,  has 
the  same  effect  as  carbonic  acid.  According  to  Sev- 
erini's^^  studies,  both  microscopic  and  physiologic,  the 
capillaries  also  are  dilated  l)y  carbonic  acid.  Barcroft'^'* 
has  measured  the  increase  of  acid  in  blood  coming 
away  from  the  submaxillary  gland  after  it  had  been 
stimulated  to  secretion  by  epinephrin,  and  accounts 
for  the  greater  flow  of  blood  through  the  gland,  when 
thus  made  active,  by  the  local  dilator  effects  of  the 
acid  metabolites.  As  acid  develops  in  tissues  poorly 
supplied  with  oxygen,  the  blood  vessels  locally  affected 
b}-  these  acids  might  reasonably  be  expected,  on  the 
basis  of  the  foregoing  evidence,  to  undergo  relaxation. 

An  antagonistic  factor  is  found,  however,  in  the 
action  of  H-ions  on  the  vasomotor  centers.  Oxygen 
lack,  increase  of  carbonic  acid  in  the  blood,  or  injection 
of  weak  organic  acids,  all  of  which  increase  the  H-ion 
content,  stimulate  the  vasomoter  center  and  cause 
a  rise  of  blood  pressure. •'^■^'  Thus,  in  acidosis  with 
increased  H-ions  in  the  blood,  vessels  under  nervous 
control  would  be  subjected  to  impulses  which  would 
cause  them  to  contract.  This  evidence  harmonizes 
with  that  presented  earlier,  that  in  shock  the  arterioles 
are  in  constriction.  Probably  most  veins  are  likewise 
involved  in  the  subjection  to  nervous  discharges.  The 
capillaries,  however,  would  be  affected  by  the  local 

49.  Henderson,  L.  J.:  Am.  Jour.  Ptiysiol.,   1908,  21,   441. 

50.  Hooker:   Am.   Jour.   Physiol.,    1912,  31,   58. 

51.  Gaskell:   Jour.   Physiol.,    1880,   3,   66. 

52.  Bayliss:  Jour.  Physiol.,  1901,  26,  xxxii. 

53.  Severini:  Ricerche  sulla  Innervazionc  dci  Vasi  Sanguini,  Perugia, 
1878,  p.   96;   La   Contractilita   dci   Vasi   Capillar!,   Perugia,    1881. 

54.  Barcroft:  The  Respiratory  Function  of  the  Blood,  Camljridge, 
1914,  p.  154. 

55.  Mathison:  Jour.  Physiol.,  1910,  42,  283. 


87 

increase  of  I  I-ions,  and  bciii<:(  (Hlatcd  would  be  capable 
of  holding  an  extra  amount  of  blood.  Some  veins, 
likewise,  mif;;ht  be  relax<'<l.  'I  lins  capacity  for  the  lost 
blood  would  1)e  provided  in  the  small  vessels  of  the 
tissues  rather  than  in  the  large  venous  trunks. 

2.  Increase  of  the  carbonic  acid  of  the  blood  affects 
cardiac  contraction.  As  previously  noted,  Patterson"" 
has  shown  that  when  the  H-ions  are  increased  by  this 
means,  cardiac  muscle  relaxes  to  a  greater  extent 
durmg  diastole  and  contracts  less  forcibly  in  systole, 
so  that  the  output  is  diminished.  This  condition  again 
would  tend  to  result  in  further  impairment  of  the 
circulation. 

3.  Increase  of  carbonic  acid  increases  the  viscosity 
of  the  blood.  Bence'*'^  reports  that  by  breathing  an 
atmosphere  rich  in  carbon  dioxid,  the  viscosity  of  the 
blood  may  be  increased  by  from  25  to  52  per  cent., 
and  according  to  Ferrai's'^"  experiments,  asphyxiated 
blood  has  a  viscosity  approximately  double  that  of 
o.KVgenated  blood,  the  increase  rising  as  the  carbonic 
acid  content  rises.  This  factor  would  cooperate  with 
low  arterial  pressure,  concentration  of  corpuscles,  and 
cold,  as  agencies  operating  to  produce  stagnation  of 
corpuscles  in  capillaries. 

4.  Hamburger^'^  has  noted  that  the  si':e  of  corpuscles 
is  increased  by  the  action  of  carbonic  and  other  acids. 
The  change  need  be  only  a  slight  one  to  produce 
demonstrable  results,  as,  for  example,  wdien  the 
arterial  blood  becomes  venous.  If  the  arterial  blood 
contains  an  excess  of  H-ions,  it  would  deliver 
to  the  systemic  capillaries  enlarged  corpuscles.  Cor- 
puscles stagnant  in  regions  ill  supplied  with  circulating 
blood,  where  acid  metabolites  are  most  concentrated, 
would  be  especially  subject  to  enlargement.  In  some 
cf  our  hematocrit  readings  we  found  that  the  capillary 
corpuscular  volume  was  greater  compared  with  the 
venous  corpuscular  volume  than  it  should  have  been 
according  to  the  ratio  of  corpuscular  and  venous 
counts.  The  discrepancy  was  greatest  in  severe 
acidosis.  The  larger  corpuscles  might  find  obstruction 
to  their  progress  where  smaller  corpuscles  would  not, 
and  in  any  case  might  raise  the  viscosity  of  the  blood. 

56.  Ferrai:   Arch,   di  fisiol.,  1904,  1,   385. 

57.  Hamburger:  Osmotischer  Druck  und  lonenlehre,  Wiesbaden,  190J, 
1,   296. 


88 

All  those  clTccts  of  iiicreasiii<^  the  ll-ions  of  the 
blood — relaxation  of  vessel  walls  (especially  the  capil- 
laries), weakening  of  cardiac  contraction  and  increase 
of  blood  viscosity — would  be  favorable  to  a  continu- 
ance of  low  blood  pressure.  It  seems  probaljle,  there- 
fore, that  when  acidosis  is  once  established,  it  would 
tend  to  continue  the  disturbances  of  the  circidation 
wliicli  have  been  produced  by  other  conditions. 

Vicious   Circles    in    Shock 

In  relation  to  the  observations  and  inferences  dis- 
cussed alcove,  it  is  of  interest  to  consider  some  of 
their  interrelations.  In  all  probal)ility  a  number  of 
vicious  circles  would  I)e  started  which,  if  not  inter- 
rupted, would  lead  to  an  aggravation  of  the  already 
existent  abtiormal  state,  and  which  would  account  for 
the  progressive  nature  of  fatal  shock.  The  following 
possibilities  may  have  suggestive  value: 

1.  The  retarded  blood  flow  in  cooled  capillaries 
would  result  in  a  lessened  supply  of  heat  to  the  regions 
of  stasis ;  the  parts  would  thus  become  still  cooler ; 
the  cooling  would  increase  still  further  the  viscosity 
of  the  blood,  and  thereby  the  blood  flow  in  the  capil- 
laries would  be  still  further  retarded. 

2.  Increase  in  the  number  of  corpuscles  per  cubic 
millimeter  increases  the  viscosity;  thus  the  more  the 
blood  concentrates  in  some  of  the  capillaries  the  more 
friction  would  there  be  in  driving  the  corpuscles 
through  them,  and  consequently  a  still  greater  accum- 
ulation in  these  capillaries  might  be  expected. 

3.  As  more  blood  accumulates  in  capillary  areas, 
less  is  returned  to  the  heart ;  the  arterial  pressure  in 
consequence  continues  to  fall,  the  force  driving  the 
blood  through  the  ca])illaries  is  thereby  progressively 
lessened,  and  the  tendency  for  blood  to  gather  in  the 
capillaries  where  the  passages  are  narrowest  and  the 
friction  greatest  is  continuously  augmented. 

4.  As  the  blood  pressure  falls,  the  "head"  normally 
in  the  arteries  is  largely  lost  and  becomes  insufficient 
to  maintain  the  circulation  equally  in  all  parts  of  the 
body;  the  blood  would  be  forced  through  capillaries 
in  wdiich  resistance  is  slight  rather  than  through  those 
in  which  it  is  increased;  the  blood  flow  in  cooled, 
clogged  capillaries,  as  those  of  the  limbs,  would  thus 


89 

tend     to     l)c     li^iadii.illy     (liiiiiiiislu'd,     vvilli     rcsnltniit 
greater  stasis. 

5.  An  increased  I  T-ion  content  of  the  hlodd  lessens 
the  rate  and  the  ainonnt  c)f  union  of  oxyjjjcMi  with 
hemoglobin/'*^  and  a  lowered  temi)eratiirc  (in  coolefl 
tissues)  lessens  the  rate  of  dissociation  of  the  oxygen; 
a  diminished  oxygen  supply  would  interfere  with  cellu- 
lar oxidation,  and  thus  increase  the  amount  of  fixed 
acid  in  the  blood  ;  this  in  turn  would  check  the  oxida- 
tive processes  in  the  cells  and  interfere  with  heat 
production ;  in  consequence,  through  cooling  and 
greater  acidosis,  the  abnormal  state  would  be  made 
worse. 

6.  As  arterial  i^ressure  falls  and  acid  accumulates 
in  the  blood,  the  kidneys,  because  of  the  low  pressure, 
become  less  and  less  active ;  fixed  acid  consequently 
accumulates  still  further  in  the  blood,  and  the  disturb- 
ing condition  is  thus  augmented. 

IDoubtless  there  are  still  other  ways  by  which  the 
abnormal  factors  may  interact  so  as  gradually  to  lessen 
the  chances  of  recovery  for  the  shocked  individual. 
All  these  deranging  processes,  however,  require  appre- 
ciable time  for  their  operation.  It  is  important, 
therefore,  that  the  treatment  of  shock  be  prompt,  and 
directed  toward  preventing  an  increase  of  the  unfavor- 
able conditions. 

Shock    as    ''Exemia" 

The  view  developed  in  the  foregoing  discussion  that 
in  shock  the  circulatory  difficulty  is  due  to  loss  of  blood 
from  circulation,  though  not  from  the  body,  is  one 
which  has  been  growing  in  recent  years,  as  experi- 
mental data  have  accumulated.  The  general  condition 
was  first  reasoned  out  by  Malcolm/'*'  and  later  the 
idea  w^as  greatly  elaborated  by  Henderson/"  both  of 
whom  supposed  that  the  lost  blood  w^as  gathered  in 
the  veins.  Still  later,  Mann^^  expressed  the  same  idea, 
declaring  that  in  shock  there  is  a  loss  of  circulatory 
fluid  at  a  point  beyond  vasomotor  control.  And  more 
recently  the  idea  has  been  generalized  for  various 
shocklike  states,  traumatic  and  toxic,  and  the  sugges- 

58.  Barcroft:  The  Respiratory  Function  of  the  Blood,  Cambridge, 
1914,  pp.  27  and   53. 

59.  Malcolm:   Tr.   Med.   Soc,   London,   1909,  32,   274. 

60.  Henderson:  Am.  Jour.  Physiol.,  1910,  87,  152. 


90 

tion  ofTered  that  capillary  concentration  might  occur."' 
In  all  these  states  the  essential  feature  appears  to  he 
a  draining  or  holding  back  of  blood  from  normal 
currency. 

This  view  of  "shock"  is  so  different  from  that  which 
probably  gave  reason  for  the  original  use  of  the  term — 
a  sudden  collapse  due  to  a  severe  wound — that  a 
more  descriptive  name  seems  needed.  The  general 
employment  of  the  word  "shock"  for  a  variety  of 
meanings,  as,  for  example,  emotional  shock,  shell 
shock,  concussion  shock,  besides  traumatic  or  surgical 
and  toxic  shock,  points  likewise  to  the  need  of  a  new 
designation.  The  word  cxoiiia  was  employed  by  Hip- 
pocrates and  signifies  "drained  of  blood."  As  the 
discussion  presented  above  has  indicated,  such  is  the 
condition  in  the  shocked  man  who  has  not  bled — his 
blood  pressure  is  low  because  essential  parts  of  the 
circulatory  system  have  been  drained  of  blood.  The 
term  c.vciiiia  may  properly  be  used  to  describe  this 
condition. 

A   Concept   of   the   Development  of   Shock 

OR     EXEMIA 

Although  an  addition  to  the  already  numerous 
theories  of  shock  seems  uncalled  for,  the  facts  pre- 
sented in  the  present  series  of  papers  may  be  worthy 
of  an  attempt  at  correlation  in  a  general  statement. 
These  facts  may  be  listed  as  follows :  There  are  pri- 
mary wound  shock  with  rapid  lowering  of  arlerial 
pressure,  and  secondary  wound  shock  with  toxemia 
and  hemorrhage,  and  later  lowering  of  the  pressure. 
Sweating  occurs,  leading  to  loss  of  fluid  and  loss  of 
heat  from  the  body.  The  blood  becomes  stagnant  and 
concentrated  in  the  capillaries,  and  as  the  blood  pres- 
sure falls  there  is  loss  of  the  alkali  reserve  of  the 
blood  (acidosis)  roughly  corresponding  to  the  drop 
in  pressure.  After  the  discussion  in  the  foregoing 
pages,  how  may  these  facts  be  set  together  con- 
sistently? 

Primary  wound  shock — dusky  pallor  ;  rapid,  thready, 
low  tension  pulse;  hypotension;  sweating;  thirst,  and 
restlessness — may  come  on  so  soon  after  injury  as  to 
be  accounted  for  only  as  the  result  of  nervous  action. 

61.  Medical  Research  Committee,  London:  Memorandum  upon  Surgical 
Shock,  Brit.  Med.  Jour.,  March  24,  1917.  Jancway  and  Jackson:  Proc. 
Soc.  Exper.  Biol,  and  Med.,  1915,  t2,  193. 


91 

The  organization  of  tlic  individual  (for  example,  a 
"high  strung"  temperament),  fear  and  fatigue  prob- 
ably provide  favorable  eonditions  for  the  nervous 
response.  Cowell's  o1)servation  of  fainting  after 
slight  wounds  may  perhaps  l)e  regarded  as  a  transient 
state  which  in  true  shock  is  more  persistent.  Sweating 
and  exposure  lead  to  rapid  loss  of  heat  from  the  l)ody ; 
previous  sweating,  wetness  of  the  clothing,  and  low 
external  tem])crature  favor  the  process.  Inactivity 
of  the  wounded  man  and  absence  of  shivering  lessen 
heat  protection.  Thus  the  body  1)ecomes  cold,  espe- 
cially the  surface  and  extremities.  In  consequence  of 
the  low  blood  pressure,  aided  by  the  chilled  tissues, 
there  is  a  stagnation  of  corpuscles  in  the  capillaries. 
The  onward  flow  here  checked  undergoes  concentra- 
tion, so  that  the  capillary  red  count  is  high.  Prolonged 
lack  of  fluid  and  sweating  may  favor  the  stagnation 
and  further  concentration  of  the  blood.  The  low 
arterial  pressure  can  continue  a  flow  through  easy 
channels,  but  is  insufficient  to  maintain  the  normal 
flow  where  resistance  is  high.  Thus  cooled  regions 
receive  less  heat  from  the  interior  of  the  body  and 
tend  to  become  cooler,  and  thus  in  turn  more  blood 
accumulates.  By  accumulation  in  capillaries  the  return 
of  blood  to  the  heart  is  lessened  until  a  persistent  low 
blood  pressure  becomes  established.  The  blood  lost 
from  currency  produces  a  state  equivalent  to  hemor- 
rhage. Any  true  hemorrhage  therefore  exaggerates 
the  existent  shock  (exemia). 

When  a  wound  has  not  caused  a  primary  fall  of 
blood  pressure,  but  has  rendered  the  control  of  the 
circulation  unstable,  unfavorable  conditions,  such  as 
cold,  hemorrhage  and  toxemia,  will  bring  about  the 
same  sequence  of  events  that  is  seen  in  primary  shock. 

As  the  low  blood  pressure  continues,  the  alkali 
reserve  of  the  blood  is  reduced  (acidosis).  Previous 
starvation  and  fatigue  would  favor  the  development 
of  acidosis.  This  state,  by  locally  relaxing  vessels 
which  are  not  under  nervous  control,  by  weakening 
cardiac  contraction,  and  by  increasing  the  viscosity  of 
the  blood,  tends  to  make  worse  the  dangerous  condi- 
tion which  has  been  established.  And,  as  pointed  out 
in  an  earlier  paper,  the  individual  with  acidosis  is 
sensitized    so    that    operation,    because    still    further 


92 

increasing^  tlie  acidosis  and  slill  furllicr  U)\vcrinij  lilood 
pressure,  becomes  hazardous. 

This  conception  of  the  events  that  take  i)lace  in  a 
vvounded  man  who  passes  into  shock  j,Mves  a  reasonable 
account  of  the  primary  elTcct  of  wounds,  the  intlucnce 
of  cold  in  continuinj:^  the  low  blood  pressure  or 
inducing  it  when  the  circulatory  ajiparatus  is  unstable, 
the  influence  of  warmth  in  restoring:  him  in  part  to  a 
fit  condition,  and  the  slowness  of  a  full  recovery. 
It  leaves  unsettled  the  occasion  for  the  primary  fall  of 
pressure,  thou<;h  the  sujijiJjcstion  is  offered  that  it  may 
be  of  rertbx  character,  .'similar  to  fainting.  The  con- 
ception offers  a  hopeful  outlook  for  the  care  of  the 
shocked  man,  because  two  of  the  most  potent  factors 
making  his  chances  unfaxorablc,  cold_  and  acidosis, 
can  be  controlled. 


THE    PREVENTIVE    TREATMENT     OF 
WOUND     SHOCK. 

W.     B.     CANNON,     M.D.     (BOSTON) 

Captain,    M.    R.    C,   U.    S.    Army 

JOHN    FRASER 
Captain,   M.   C,  R.  A.   M.   C. 

E.    M.    COWELL 

Captain,  R.   A.    M.   C,   S.   R. 
FRANCE 

Introduction 

Whatever  the  nature  of  the  bodily  changes  which 
underlie  the  state  of  shock,  it  is  evident  that  the  cir- 
culatory functions  are  in  a  precarious  condition,  and 
that  the  heart,  nervous  system  and  other  organs  are 
suffering  from  an  insufficient  blood  supply.  Every- 
thing should  be  done  to  promote  the  factors  favorable 
to  restoration  of  a  normal  and  stable  blood  flow,  and 
anything  unfavorable  to  such  restoration  should  be 
scrupulously  avoided.  There  are  certain  practices, 
such  as  the  prompt  arrest  of  hemorrhage,  the  lessen- 
ing of  sepsis  by  appropriate  dressings,  and  the  reduc- 
tion of  pain  by  suitable  splints,  by  the  judicious  use 
of  morphin,  and  by  careful  transport,  that  are  gen- 
erally recognized  as  important  measures  in  the  care  of 
a  wounded  man  who  is  shocked  or  liable  to  shock. 
Besides  these  there  are  other  precautions  which  are 
suggested  by  observations  reported  in  the  foregoing 
papers. 

In  previous  papers  of  this  series,  evidence  has  been 
afforded,  among  others,  on  the  following  points : 

1.  Cooling  of  a  person  in  shock  is  attended  by  a 
further  lowering  of  an  already  low  blood  pressure  or 
by  continuance  of  the  pressure  at  a  low  level. 

2.  Surgical  operation  performed  on  a  person  in 
shock  is  accompanied  by  a  rapid  and  large  increase  of 
an  acidosis  which  is  already  present,  and  by  a  corre- 
spondingly sudden  and  extensive  fall  in  an  existent 
low  arterial  pressure. 

These  two  sets  of  changes  are  both  harmful,  and 
may  turn  the  slender  cliances  of  a  shocked  man  defi- 


94 

nitely  away  from  safely  ami  into  disasler.  The 
(lantjers  of  both  coohii";  and  surgical  operation,  how- 
ever, can  be  dealt  with  in  ways  which  will  lead  to 
their  avoidance.  The  protection  of  the  wounded  man 
against  coiulitit)iis  which  would  develop  or  increase 
shock  offers,  we  believe,  the  greatest  hn\)v  for  his 
recovery. 

In  the  following  account  are  i)resented  suggestions, 
based  on  preceding  papers,^  for  the  prevention  and 
early  treatment  of  wound  shock  and  for  the  i)rei)ara- 
tion  of  the  shocked  man  for  surgical  operation. 

TiiK  Prevention  and  1£arlv  Treatment  of 
Wound    Shock 

The  reader  will  recall  that  of  the  three  classes  of 
wounds,  Class  B,  those  of  moderate  severity,  may, 
through  the  effects  of  cold,  hemorrhage  and  toxemia, 
develoj)  into  secondary  wound  shock  ;  ruid  that  Class  C, 
those  of  such  severity  as  to  endanger  life  unless  early 
surgical  treatment  is  given,  show  primary  wound 
shock.  Without  proper  care  the  case  of  secondary 
shock  may  be  unnecessarily  fatal,  and  with  care  the 
patient  with  primary  shock  may  be  tided  over  a  critical 
period  and  brought  to  a  casualty  clearing  station  in  a 
still  operable  condition. 

The  actual  carry  along  the  line  of  e\acuation  will 
vary  greatly,  according  to  the  military  situation  and  to 
uncontrollable  circumstances,  such  as  the  weather,  for 
example.  The  average  wounded  man  on  the  Western 
front  passes  through  the  hands  of  several  relays  of 
bearers  and  at  least  three  or  four  medical  officers 
before  he  reaches  a  clearing  station.  Stretcher  carry- 
ing along. narrow  trenches  in  the  dark  is  laborious  and 
slow  work,  even  under  good  weather  conditions.  Bad 
weather  doubles  or  quadru])lcs  the  time  ref|uired  for 
the  first  stages  of  the  journey. 

If  a  man  is  hit  in  the  front  line  trenches  he  may  be 
at  least  one  or  two  hours'  journey  away  from  the 
regimental  aid  post.  And  a  man  in  a  working  party, 
a  little  farther  back,  may  be  as  far  away  from  the 
advanced  dressing  station.  The  ol)ser\ations  recorded 
in  the  article  on  the  initiation  of  wound  shock  have 
shown  that  it  is  in  this  stage  of  the  journey  that  sec- 

1.  Cannon,  W.  B. :  Acidosi.s  in  Cases  of  Shock,  Hemorrhage  and 
Gas  Infection,  p.  47.  Cowell,  E.  M.:  The  Initiation  of  Wound  .Shock, 
p.  61. 


95 


ondary  wound   shock  develops,  and   that  one  of   th<- 
chief  factors  in  its  initiation  is  loss  of  hody  heat. 

To  send  hlankets  to  all  parts  of  the  line  is  impos- 
sihle,  hut  hy  the  adoption  of  a  waterproof  shcct- 
hlanket  "packet"  system  a  stetcher  ])reparcd  for  use 
is  provided  willi  means  for  prcvcuUu^  excessive  loss 
of  hody  heat.  Keferencc  to  h^ij^ure  1  will  make  clear 
this-  simple  method  of  carryinp^  a  dry  hiankct.     This 


<  -20"    > 

-  3'---> 


Fig.     1. — ]\Ietliod    of    carrying    a    dry    blanket. 

method  has  already  been  put  into  practice  in  a  large 
part  of  the  line. 

All  regimental  stretchers  at  advanced  bearer  posts 
in  the  front  line,  and  stretchers  carried  by  working 
parties,  should  be  equipped  with  this  packet.  The 
regimental  bearers  should  be  insistently  instructed  by 
their  medical  officer  as  to  the  importance  of  doing 
everything  to  prevent  wound  shock.     The  wounded 


96 

man  should  be  fj^iiardcd  as  much  as  possible  against 
loss  of  heat.  Efticient  first-aid  should  be  given  rapidly 
without  unduly  exjjosing  the  patient  to  the  cold  for  a 
prolonged  period.  A  hot  drink  should  be  given  at  the 
earliest  moment.  Then,  having  been  carefully  wrapped 
up.  the  patient  should  be  carried  down  wilh  all  speed 
to  the  regimenlal  aid  post.  A  well  trained,  intelligent 
orderly  might  be  entrusted  to  give  a  tablet  of  morphin 
(one-fourth  grain)  by  mouth  in  cases  of  severe  pain. 
A  note  of  this  treatment  should  be  made  in  the  usual 
way. 

At  the  regiincnta!  aid  post  it  is  wise  to  consider  the 
general  condition  of  the  patient  first  and  his  wound 
second.  A  dry  stretcher  with  three  blankets  should 
always  be  in  readiness  for  a  possible  case  at  any  time 
of  the  day  or  night.  In  the  properly  equipped  aid 
post  there  will  be  a  constant  source  of  heat,  such  as 
can  be  supplied  by  any  good  type  of  small  closed  stove 
or  a  small  open  brazier  with  a  flue  to  carry  off  coke 
fumes.  Space  will  be  limited ;  but  an  open  stretcher, 
together  with  three  blankets  folded  lengthwise  three 
times,  may  be  kept  supi)orted  horizontally  against  the 
wall  of  the  dugout  behind  the  stove.  A  dry  stretcher 
and  a  supply  of  warm  blankets  will  thus  always  be  at 
hand.  A  tin  of  water  may  be  kept  standing  on  the  fire 
to  provide  for  hot  drinks  and  for  filling  hot-water 
bottles. 

As  soon  as  a  patient  arrives  he  should  be  given  a 
few  ounces  of  hot  drink,  and  his  wet  boots  and 
puttees  removed,  along  with  any  other  clothing  which 
may  cover  wounds.  Meanwhile  the  dry  stretcher  is 
prepared  by  arranging  the  first  two  blankets  so  that 
four  folds  will  come  underneath  the  patient  (Fig.  2). 
The  blankets  are  covered  temporarily  with  a  water- 
proof sheet  to  prevent  soiling  while  wounds  are  being 
dressed.  The  man  is  now  transferred  to  this  prepared 
stretcher,  which  is  supported  on  trestles  and  stands 
well  over  the  stove.  The  third  or  free  fold  of  each  of 
the  lower  two  blankets  hangs  (Unvn  on  either  side  and 
helps  to  form  an  enclosed  warming  chamber.  If  there 
is  no  constant  source  of  heat,  a  hot  air  chamber  may 
be  made  in  a  few  minutes  by  use  of  a  Primus  or 
Beatrice  stove.^ 

2.  A  Primus  stove  of  ordn.Tnce  pattern  will  burn  a  gallon  of  paraflin 
in   twenty-four   hours  if   operating  continuously. 


97 


The  patient  is  lunv  bcroiiiiiij^'  vvaniicd,  whih;  the 
me(hcal  officer  is  atteiKhnj,'  to  the  sur^^ical  cleansini^  of 
the  wounds  and  neij^hhcjrinj^  parts,  and  is  a])];lying 
projjcr  dressinj^^s  and  sjjhnts.  As  sgon  as  the  dressings 
are  finished,  weU  guarded  h(jt  water  bottles  arc  placed 
in  each  axiUa  and  a  third  across  tlie  loins  or  between 
the  legs;  and  the  thirrl  blanket,  which  is  doubled 
lengthwise,  is  laid  over  the  patient.  The  two  warmed 
blankets  which  have  been  hanging  to  form  the  sides 
of  the  hot  air  chamber  are  IJfted,  carried  over  the 
patient,  and  tucked  in.  lie  now  has  four  folds  of 
blanket  over  him  as  well  as  underneath. 

Finally,  just  before  the  patient  is  sent  off,  he  is  given 
a  hot  drink  'of  sweetened  tea  in  which  a  dram  of 
sodium   bicarbonate   is   dissolved. 


ilSp^-s^ 


BU^Uh-l 


--eUU.N'z 


fS3 


a..^. 


Fig.    2. — Method    of    folding    three    blankets    to    give    four    folds   above 
and  below  the  patient;   also  the  formation  of  a  hot  air  chamber. 


At  the  advanced  dressing  station  the  warming  proc- 
ess with  the  Primus  stove  may  be  repeated,  but 
usually  without  changing  the  stretcher  and  blankets. 
Meanwhile,  any  necessary  treatment  is  carried  out. 
Before  the  patient  is  sent  on,  a  hot  sweetened  alkaline 
drink  is  administered  as  described  above,  and  a  fresh 
set  of  hot  water  bottles  is  put  in  place. 

The  next  stage  of  the  journey  is  usually  undertaken 
by  means  of  some  mechanical  transport,  such  as  a 
narrow  gage  railway  or  a  motor  ambulance.  The  cars 
are  at  present  warmed,  so  that  there  is  a  lessened 
chance  of  loss  of  body  heat  on  the  final  stages  of  the 
journey. 

At  the  clearing  statio)i,  application  of  warmth  should 
be  emphasized  as  the  most  important  part  of  the  treat- 
ment in  all  serious  cases.     \\'hile  the  patient  is  being 


98 

undressed  ami  iiuule  ready  for  operation,  he  should 
be  put  over  the  same  hot  air  chamber  as  has  already 
been  described.  Electric  warming  apparatus,  to  be 
set  over  the  patient,  is  at  hand  to  aj^ply  as  soon  as  he 
is  ready,  but  it  will  not  permit  handlinp^  and  treatment 
as  will  the  hcatin_sj[  from  below. 

W  bile  c)peratin<j[.  at,fain,  every  care  must  be  taken  to 
l)revcnt  loss  of  heat,  even  in  summer.  An  electrically 
heated  ei)erating  table  is  invaluable. 

Modifications   of   Trf.vtmicnt   in    Battlk 
Conditions 

The  outlines  of  early  treatment,  sketched  in  the 
preceding  paragraphs,  apply  to  such  conditions  on  the 
Western  front  as  are  "normal"  for  the  greater  part 
of  the  year.  In  battle,  the  early  exposure  to  cold  will 
not  be  so  important  in  most  cases.  But,  as  a  result 
of  previous  fatigue  and  loss  of  body  fluid  by  sweating 
and  hemorrhage,  together  with  the  establishment  of 
infection  and  the  onset  of  toxemia,  secondary  wound 
shock  develops.  Whereas  the  appearance  and  degree 
of  primary  wound  shock  dei)end  on  the  degree  of 
damage  done  to  a  vital  organ,  secondary  wound  shock 
is  proportionate  to  the  length  of  time  the  pernicious 
factors  are  allowed  to  work  —  in  other  words,  to  the 
ijeriod  during  which  the  wounded  man  is  "lying  out." 

In  the  rush  of  dealing  with  largo  numliers,  it  will 
be  impossible  in  the  line  to  attend  to  all  the  details 
described  above.  Large  drafts  of  hot  sweet  tea  made 
alkaline  with  sodium  bicarbonate  can,  however,  be 
easily  provided,  and  should  be  given  whenever  the 
shocked  patient  complains  of  thirst  at  the  dressing 
station  or  at  any  other  suitable  point  on  the  way  down 
to  the  clearing  station. 

Protection  Against  tiif.  Effects  of  Surgical 
Operation 

Evidence  presented  in  an  earlier  paper  showed  that 
the  acidosis  which  prevails  in  cases  of  low  blood  pres- 
sure is  associated  with  such  sensitization  of  the  body 
that  surgical  operation  may  result  in  a  serious  increase 
of  the  acidosis  and  a  perilous  sinking  of  the  blood 
pressure.  The  question  as  to  the  causal  relation 
between  low  pressure  and  acidosis  has  been  discussed, 
and  it  appears  that  the  two  conditions  may  interact, 


99 

each  conlribiilinj^f  1o  llu;  (lcvclo|)mont  nf  llic  other. 
Under  tliesc  circunislaiices,  advaiitrige  vvoulil  he  j^aiiied 
l)y  protection  aj^ainsl  each  of  the  conchtions — first, 
against,  the  development  of  the  sensitizing  acidosis, 
and,  secondly,  against  the  increase  of  acidosis  and  the 
further  fall  of  hlood  pressure  which  occur  at  opera- 
tion. 

PREOPERATIVE     PROPHYLAXIS 

In  the  acidosis  of  diabetes,  Asiatic  cholera,  nephritis 
and  other  pathologic  states,  the  urine  can  be  rendered 
alkaline  by  administration  of  sodium  bicarbonate  by 
mouth,  as  has  been  shown  by  Scllards,''  Palmer  and 
1  lenderson,^  and  other  observers.  The  change  in  the 
reaction  of  the  urine  implies  an  abundance  of  available 
alkali  in  the  blood.  Ilie  possibility  of  fortifying  the 
body  against  a  reduction  of  the  alkaline  reserves  in 
surgical  cases  was"  demonstrated  by  Caldwell  and 
Cleveland.'"'  They  gave  sodium  bicarbonate  by  mouth 
and  found  that  the  normal  reserves  can  be  so  increased 
as  to  avoid  wholly  the  drop  in  carbon  dioxid  capacity 
that  occurs  in  the  period  preparatory  to  operation,  and 
also  to  reduce  by  half  the  rate  of  drop  that  takes  place 
during  operation.  The  degree  to  which  a\'ailable  alkali 
can  be  provided  by  giving  sodium  bicarbonate  by 
mouth  in  cases  of  shock  and  gas  infection  is  shown  in 
the  following  case : 

German  Unfcroffizicr  H. — Admitted,  August  15,  with  wounds 
of  both  buttocks,  but  in  good  condition.  The  next  day  tlie 
pressure  was  low  (78  and  56),  and  the  carbon  dioxid  capacity 
48  per  cent.  Alkaline  drink  had  been  started'  and  was  con- 
tinued at  two-hour  intervals.  On  the  second  day  the  wounds 
were  evidently  extensively  infected  with  gas,  but  the  blood 
pressure  was  102  and  66,  and  the  blood  had  a  carbon  dioxid 
capacity  of  61  per  cent.  In  spite  of  operation,  the  infection 
spread  and  death  resulted. 

The  results  obtained  in  the  foregoing  case  confirm 
the  results  obtained  by  others  in  showing  that  by 
administration  of  sodium  bicarbonate  the  alkaline 
reserves  of  the  body  can  be  greatly  increased  even  in 
unfavorable  circumstances.  Since  acidosis  develops 
in  shock  and  involves  a  definite  risk  when  operation 

3.  Sellards:  Philippine  Jour.  Sc,  1910,  5,  313;  Bull.  Johns  Hopkins 
Hosp.,    1912,    33.    289. 

4.  Palmer,  W.  W.,  and  Henderson,  L.  J.:  Clinical  Studies  on  Acid 
Base  Equilibrium  and  the  Nature  of  Acidosis,  Arch.  Int.  Med.,  August, 
1913,  p.    153. 

5.  Caldwell  and  Cleveland:  Surg.,  Gyncc.  and  Obst.,  1917,  25.  22. 


100 

is  undertaken,  its  a\oi(lancc  should  he  sought.  The 
reconinienihitiun  is  ottered  that  wounded  men  he  pro- 
vided with  a  warm  drink  containint;;  a  dram,  or  4 
<jrams,  of  sodium  hicarhonatc  at  suital)le  rehiy  posts 
on  their  way  from  the  front  to  casuaUy  clearing  sta- 
tions, as   indicated   in  the   first   section   of   ihi--   paper. 

(>i'i:kativi-:    i'kci'Iiylaxis 

When  a  wounded  man,  hadly  shocked,  is  hrought  to 
a  clearino-  station,  he  commonly  must  he  oj)erated  on 
in  spite  of  a  low  hlood  ])ressure  and  its  attendant 
acidosis.  The  lapse  of  time  when  a  man  is  in  this 
condition  gives  op]K)rtiniity  for  the  extension  of  infec- 
tive {processes  which  gravely  menace  his  chances.  The 
surgeon  has  to  choose,  therefore,  hetween  an  opera- 
tion when  the  risk  is  serious,  and  a  delay  during  which 
toxemia  may  develop  to  a  menaciiig  degree. 

The  low  hlood  pressure  of  shock  has  heen  met 
hitherto  hy  the  injection  of  normal  or  hy])ertonic  salt 
solution,  or  hy  comhinations  of  salt  solutions  and  gum. 
There  is  no  doubt  that  in  some  cases  such  injections 
have  had  definitely  beneficial  effects.  As  shown  in 
the  previous  papers,  part  of  the  pathology  of  shock  is 
due  to  a  loss  of  fluid  from  the  circulation  and  con- 
sequent concentration  of  the  hlood.  The  injection  of 
salt  solution  adds  fluid  to  the  body  and  improves  the 
circulation,  so  that  the  concentration  is  soon  abolished," 
and  the  ^•iscosity  of  the  stagnant  blood  lessened.  In 
such  cases,  however,  the  degree  of  acidosis  had  not 
been  determined,  and  injection  of  physiologic  sodium 
chlorid  solution  or  Ringer's  solution  makes  no  provi- 
sion against  such  critical  turns  as  have  been  encoun- 
tered during  operation  or  shortly  thereafter  in  con- 
sequence of  increased  acidosis."  Not  only  does  ordi- 
nary salt  xjjution  fail  to  combat  acidosis,  it  actually 
increases  an  already  existent  acidosis.  Milroy""  has 
recently  shown  that  hemorrhage  results  in  a  loss  of 
reserve  alkali,  and  that  then  injection  of  sodium 
chlorid  solution  alone  causes  a  greater  Il-ion  concen- 
tration of  the  blood  exposed  to  a  given  pressure  of 
carbon  dioxid  than  was  present  before  the  injection. 

6.  Cannon,  W.  B.;  Fra.ser,  John,  and  Hooper,  A.  N. :  Some  Altera- 
tions in  Distriliution  and  Character  of  Blood  in  Shock  and  Hemorrhage, 
p.  32,  Cases  65  a  and  60  a. 

7.  Cannon,  \V.  B. :  Acidosis  in  Cases  of  Shock,  HeniorrhaKC  nnd  Ci.-is 
Infection,  p.   47. 

8.  Milroy:   Jour.    Physiol.,    1917.    51,    277-279. 


101 

Wh.'il  is  w.'ink'd  is  a  fliiiH  lliat  will  have  the  arlvan- 
1a<;c's  already  (Icnioiislralcd  for  salt  solutions  ■ —  thin- 
ning of  .concentrated  blood,  lessening  of  viscosity  and 
increase  of  blood  flow  with  restoration  of  arterial 
pressure  —  together  with  antagonism  to  the  state  oi 
acidosis.  vSuch  a  fluid  is  found  in  sodium  bicarbonate 
solution.  I  lowell"  observed  years  ago  that  alkaline 
injections  (sodium  bicarbonate)  into  a  vein  or  info 
the  rectum  raised  a  systolic  pressure  of  60  or  70  mm. 
permanently  to  the  normal  level,  and  caused  a  marked 
increase  in  the  force  of  the  heart  beats.  If  the  pres- 
sure was  lower  (from  20  to  30  mm.)  it  was  raised  to 
60  or  70  mm.  Also  the  efifects  were  relatively  per- 
manent, lasting  one  or  more  hours.  These  observa- 
tions were  confirmed  by  Dawson.^"  Either  intravenous 
or  intrarectal  injections  of  sodium  bicarbonate  can 
restore  the  alkali  reserve  and  abolish  an  existent 
acidosis. ^^ 

Injection  of  a  fluid  that  will  increase  blood  pressure 
has  dangers  in  itself.  Hemorrhage  in  a  case  of  shock 
may  not  have  occurred  to  a  marked  degree  because 
blood  pressure  has  been  too  low  and  the  flow  too  scant 
to  overcome  the  obstacle  offered  by  a  clot.  If  the 
pressure  is  raised  before  the  surgeon  is  ready  to  check 
any  bleeding  that  may  take  place,  blood  that  is  sorely 
needed  may  be  lost.  Fortunately,  the  injection  may 
be  made  at  the  start  of  operation,  just  after  the 
patient  has  been  prepared  and  when  the  surgeon  is 
ready  to  stop  any  hemorrhage,  and  it  may  continue  as 
the  operation  proceeds. 

The  fluid  that  was  injected  in  the  cases  recorded 
below  was  a  4  per  cent,  solution  of  sodium  bicarbo- 
nate. Since  1.5  per  cent,  sodium  bicarbonate  is  approx- 
imately isotonic  wath  the  blood  plasma,  the  4  per  cent, 
solution  is  rather  strongly  hypertonic.  It  had  previ- 
ously been  employed,  however,  in  treating  cases  of 
diabetic  coma,^-  and  if  introduced  slowly  (at  the  rate 
of  an  ounce  a  minute),  it  causes  no  noteworthy  altera- 
tion of  the  blood.  The  fluid  should,  of  course,  be 
delivered  to  the  body  at  approximately  body  tempera- 
ture —  it  may  be  a  few  degrees  warmer,  but  should 
not  be  colder,  than  that.     If  the  solution   is  passed 

9.   Howell:  Am.  Jour.  Phvsiol.,  1900,  4.   14. 

10.  Dawson:  Am.    Tour.   Phvsiol..   1904,    10.   35. 

11.  Milroy:    Jour.    Physiol.,   1917,    51,    278-2S1. 

12.  Peabody:   Am.  Jour.   Med.   Sc,   1916,   151.   198. 


102 

tlirniic[h  a  tube  of  oonsidciahlc  lent^th  before  it  enters 
the  \cin.  it  should  ha\e  a  temperature  maintained 
I)etwecn  110  and  115  F. 

Tlie  boibng  of  sodium  l)icarbonate  in  solution 
ehanges  it  to  sodium  carbonate.  Since  the  bicarbonate 
should  be  injected,  it  should  not  be  boiled.  The  solu- 
tion should  be  made  just  before  it  is  to  be  used,  by 
the  addition  to  warm  sterile  water  the  ])r()|)er  amount 
of  the  sterile  salt." 

To  inject  the  solution  it  is  usually  not  necessary  to 
lay  bare  a  vein  and  introduce  a  cannula.  If  a  small 
rubber  tube  is  drawn  around  the  upper  arm  as  a 
tourniquet  and  held  by  a  looped  twist  (not  so  tightly 
as  to  obstruct  the  arterial  flow,  which,  it  will  be  notecl, 
has  a  low  pressure),  the  veins  in  the  elbow  will  in 
most  cases  become  sufticientiy  prominent  to  permit  a 
hollow  needle  to  be  introduced  into  one  of  them.  The 
lumen  of  the  needle  should  Ije  large  enough  to  permit 
a  pint  of  the  bicarbonate  solution  to  pass  in  fifteen  or 
twenty  minutes  when  the  head  of  pressure  is  only  2 
or  3  feet.  A  glass  reservoir  marked  in  ounces  permits 
a  judgment  as  to  the  proper  rate  of  flow.  As  soon  as 
the  needle  enters  the  vein,  an  outflow  of  blood  through 
the  lumen  gives  evidence.  When  the  blood  thus 
appears,  the  tourniquet  should  be  pulled  loose,  the 
rubber  tul)ing  full  of  the  solution  should  be  connected 
with  the  needle,  and  the  flow  allowed  to  start.  In 
some  few  cases  the  veins  are  so  obscure  as  to  make 
this  procedure  difficult  or  impossible ;  in  that  case  the 
needle  or  a  small  cannula  must  be  inserted  into  the 
bared  vessel. 

The  following  cases  illustrate  results  which  have 
been  obtained  when  the  solution  of  sodium  bicarbonate 
has  been  injected  in  the  manner  described  above: 

Private  R.  M.,  wounded  9:30  p.  m.,  Septeml)er  24,  sustain- 
ing a  compound  fracture  of  llie  left  tibia  and  fil)ula,  and  a 
wound  of  tlie  liand,  was. admitted,  11:30,  .September  25,  with 

13.  An  ideal  injection  fluid  for  shock  cases  would  be  a  solution  with 
colloid  added,  as  Bayliss  (Proc.  Roy.  Soc,  1916,  89.  380)  has  sug- 
gested, for  example,  one  containing  sodium  hicarhonatc  in  proper  amount 
and  6  per  cent,  gum  acacia.  (Sec  further  Bayliss:  Injections  to  Replace 
Blood,  Memorandum  1,  of  Reports  of  the  Special  Investigation  Commit- 
tee on  Surgical  Shock  and  Alhed  Conditions,  Nov.  25,  1917.)  Unfor- 
tunately, tlie  gum  contains  calcium,  which  precipitates  as  calcium  car- 
bonate as  sodium  bicarbonate  is  added.  If  this  precipitate  is  filtered  out, 
the  solution  has  the  advantages  of  being  both  alkaline  and  viscous.  The 
Medical  Research  Committee  is  preparing  to  provide  in  bottles  sterile 
solutions  of  6  per  cent,  gum,  to  which  2  per  cent,  sodium  bicarbonate 
has  been  added,  and  the  deposit  filtered  out. 


103 

severe  gas  infection  of  tlie  leg;  lemi)erature  %;  hloof]  pres- 
sure, 96  and  50.  Operation  was  begun  at  12:40;  tlic  carhon 
(lioxid  capacity,  40  jjcr  cent.  One  pint  of  sodium  liicarhonate 
solution  was  injeclcd.  Operation  ended  at  1:25;  Mood  pres- 
sure, 100  and  60;  carhon  dioxid  capacity,  6.^  per  cent.  The 
pressure  was  lower  in  the  afternoon  (4:30),  74  and  46,  hut 
the  next  morning  it  was  112  and  66,  and  it  did  not  again  fall 
helow  normal  limits. 

Private  J.  B.  was  admitted,  Septemher  24,  willi  a  gunsliot 
wound  of  the  head  (three  deep  lacerations),  contusifjn  of  left 
eye,  fracture  of  hoth  l)oncs  of  the  left  leg,  and  the  left  foot 
hlown  off.  Unconscious  from  cerebral  injury.  Blood  pres- 
sure at  11:35,  54  and  20.  Operation  begun  at  11:47;  carI;on 
dioxid  capacity,  42  per  cent.  One  pint  of  sodium  bicarbonate 
solution  was  injected.  Operation  ended  12:22;  blood  pres- 
sure 112  and  40;  carbon  dioxid  capacity,  58  per  cent.  The 
patient  lived  until  the  evening  of  the  next  day,  and  died  with- 
out regaining  consciousness. 

Private  F.  B.  was  admitted,  September  9,  with  one  foot 
mangled  and  wounds  of  the  right  thigh  and  right  shoulder. 
Wounded  at  3:30  a.  m.;  at  11:30  a.  m.,  just  after  admission, 
temperature  98.4,  pulse  144,  blood  pressure  75  and  46;  sweat- 
ing, thirsty,  face  and  lips  pale.  Operation  begun  at  2  p.  m. ; 
pulse  144,  blood  pressure  72  and  42,  carbon  dioxid  capacity, 
36  per  cent.  One  pint  of  sodium  Ijicarbonate  was  injected. 
Operation  ended  at  2:40;  pulse  120,  blood  pressure  104  and 
50.  At  11 :  30  the  pulse  was  110,  but  as  the  patient  was  asleep 
the  pressure  was  not  taken.  The  next  day  (9  a.  m.),  pulse 
98,  blood  pressure  128  and  70.  Gas  infection  required  removal 
of  leg  in  the  afternoon.  The  patient  stood  the  operation  well, 
and  made  a  smooth  recovery. 

Private  H.  H.  was  admitted,  October  3,  with  the  left  foot 
blown  off;  he  had  lost  much  blood.  The  pulse  was  thready 
and  rapid.  Operation  was  started  at  5:10;  systolic  pressure 
62;  diastolic  pressure  unreadable;  carbon  dioxid  capacity,  42 
per  cent.  One  pint  of  sodium  bicarbonate  solution  was 
injected.  Operation  ended  at  5:40;  blood  pressure  62  and  46; 
pulse  slow  and  easily  palpable.  The  next  morning  (9:30), 
pulse  96,  blood  pressure  104  and  72.    The  patient  recovered. 

Private  F.  W.  was  admitted.  September  26,  with  a  com- 
pound fracture  of  the  left  thigh  and  a  wound  of  the  left 
hand.  Wounded  11  p.  m.,  September  25.  At  4  a.  m.,  Septem- 
ber 26,  just  after  admission,  temperature  was  96.6,  pulse  132, 
blood  pressure  98  and  70.  Operation  was  begun  at  4 :  50 ; 
carbon  dioxid  capacity,  34  per  cent.  Pressure  fell  to  82  and 
50,  pulse  160.  One  pint  of  sodium  bicarbonate  solution  w-as 
injected.  At  5:35,  blood  pressure  was  110  and  85.  carbon 
dioxid  capacity,  68  per  cent.  At  9:15  a.  m..  blood  pressure 
124  and  90,  and  at  4:30  p.  m.,  pulse  120,  blood  pressure  128 
and  98.    A  smooth  recovery  followed. 


104 

Sonictitncs  a  patient  a])|)arfntly  in  a  condition  tit 
for  operation  becomes  badly  shocked  as  the  operation 
proceeds.  The  foUowinjj  case  illustrates  the  use  of 
the  bicarbonate  solution  in  such  circumstances : 

Private  D.  was  wouiulcd  by  shrapnel  at  10:vW  a.  m.,  Sep- 
icinlier  19.  He  complained  of  sweating  within  less  than  five 
minutes  of  being  hit.  Seen  by  Cowell  at  11  p.  m. ;  pulse  96, 
blood  pressure  104  and  70;  cold,  pallid,  sweating.  Admitted 
to  the  clearing  station  at  11:45;  I)lood  pressure  82  and  70, 
pulse  96,  temperature  96.  At  operation  ten  large  tears  of  the 
small  intestine  were  found,  and  much  blood  in  the  abdominal 
cavity.  At  the  end  of  operation  the  blood  pressure  was 
unreadable.  One  pint  of  sodium  bicarbonate  solution  was 
injected;  blood  pressure  rose  to  85  and  60.  In  the  evening 
the  pressure  was  86  and  60.  The  following  morning  it  was 
82  and  60,  and  the  patient  was  in  excellent  condition.  That 
evening  the  pressure  was  102  and  80.  On  the  next  morning, 
September  21,  the  pressure  was  112  and  90.  The  recovery 
was  uneventful. 

The  foregoing  cases  slunv  liial  an  alkaline  injection 
at  the  start  of  anesthesia  prevents  the  dangerous 
depressive  efYects  which  the  anesthetic  and  operative 
]^rocedures  have  in  cases  of  shock  with  acidosis.  The 
operation  ends,  not  with  an  increase  of  the  existent 
acidosis,  but  with  the  acidosis  overcome  and  a  normal 
alkaline  reserve  provided.  And  the  blood  pressure, 
instead  of  being  perilously  lowered,  is  actually  raised 
during  the  critical  period.  The  blood  pressure  may 
fall  to  some  extent  later,  but  the  improved  state  of 
the  patient  during  operation  is  unmistakable,  and  the 
subsequent  course  of  shock  cases  in  which  operation 
has  been  performed  with  the  precautions  described 
above  has  been  highly  gratifying. 

In  concluding  this  scries  of  papers,  we  take  pleasure  in 
expressing  our  thanks  to  Col.  Cuthbert  Wallace,  C.  M.  C, 
A.  M.  S.,  and  to  Col.  T.  R.  Elliott  for  facilitating  arrange- 
ments to  carry  on  the  work  and  for  counsel ;  to  Lieut.-Col. 
Winder,  R.  A.  M.  C,  for  cooperative  interest;  and  to  the 
Medical  Research  Committee  and  the  American  Red  Cross 
in  France  for  instruments  used  in  the  investigations. 


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